Hand Rehabilitation: A Quick Reference Guide and Review

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Author: Susan Weiss OTR L CHT | Nancy Falkenstein OTR L CHT

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11830 Westline Industrial Drive St. Louis, Missouri 63146

HAND REHABILITATION: A QUICK REFERENCE GUIDE AND REVIEW, SECOND EDITION Copyright © 2005, Elsevier, Inc. All rights reserved.

0-323-02610-9

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: [email protected]. You may also complete your request on-line via the Elsevier Science homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. Previous edition copyrighted 1999 International Standard book Number: 0-323-02610-9 Publishing Director: Linda Duncan Managing Editor: Kathy Falk Developmental Editor: Melissa Kuster Deutsch Editorial Assistant: Colin Odell Publishing Services Manager: Linda McKinley Senior Project Manager: Jennifer Furey Design manager: Gail Morey Hudson Printed in the United States of America Last digit is the print number:

9 8 7 6 5 4 3 2 1

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Contributors

Susan Weiss and Nancy Falkenstein developed and contributed to all chapters. Contributors are listed in alphabetical order. Contributed topics are italicized. Randall D. Alley, BSc, CP, FAAOP ISPO, ABC, Chair Upper Limb Prosthetic Society Innovative Neurotronics, Inc. Thousand Oaks, California Congenital Anomalies/Amputations/Prosthetics Jacqueline Alton St. Petersburg, Florida Wounds/Infection Bambi L. Anderson, OTR/L Clinical Specialist, Upper Extremity Prosthetics Otto Bock Health Care Minneapolis, Minnesota Congenital Anomalies/Amputations/Prosthetics Karen Baker, PT, Cert. MDT Physical Therapist Outpatient Physical Therapy Tampa Bay Orthopaedic Specialists St. Petersburg, Florida Hodge Podge of Treatment Techniques

Dale G. Bramlet, MD Clinical Associate Professor University of South Florida Tampa, Florida Director of Hand Surgery Orthopaedic Surgery Bayfront Medical Center St. Petersburg, Florida Fractures George H. Canizares, MD Orthopaedic Surgeon All Florida Orthopaedic Association St. Petersburg, Florida Sports Injuries of the Upper Extremity Philip A. Davidson, MD Assistant Clinical Professor Surgery, Division—Orthopedics University of South Florida College of Medicine Tampa, Florida Tampa Bay Orthopaedic Specialists St. Petersburg, Florida Elbow, Shoulder

Brigitte Borsh-Zimmer, OTR/L, CHT Clinical Manager Occupational Therapy—Hand Therapy Clinic Mease Countryside Hospital Safety Harbor, Florida Cumulative Trauma and Differential Diagnosis

A. Lee Dellon, MD Professor of Plastic Surgery, Professor of Neurosurgery Johns Hopkins University Baltimore, Maryland Professor of Plastic Surgery, Neurosurgery, and Anatomy University of Arizona Tucson, Arizona Neuroanatomy and Sensory Reeducation

Roxanne C. Bottum, OTR/L, CHT Director of Hand Therapy Occupational Therapy All Florida Orthopaedic Associates St. Petersburg, Florida Cumulative Trauma and Differential Diagnosis

Lloyd Allen Deneau, BS, CPT Director of Physical Therapy Physical Therapy Commonwealth Rehabilitation Largo, Florida Shoulder

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Contributors

Karen Dhanens, OTR/L, CHT Occupational Therapy Trinity Medical Center Rock Island, Illinois Anatomy Extravaganza

Jodi Jones Knauf, OTR, PAC Physician Assistant All Florida Orthopaedics St. Petersburg, Florida Drugs Commonly Encountered in Hand Therapy

Jon J. Ehrich, DO, MD Board-Certified Physiatrist Diplomate, American Board of Physical Medicine and Rehabilitation Palm Beach Gardens, Florida Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy

Constance Kurash, OTR/L, CHT Independent Contractor Lee Memorial Health Systems Fort Meyers, Florida Intrinsic Mechanism

Leonard Elbaum, EdD, PT Associate Professor Department of Physical Therapy, School of Health Florida International University Miami, Florida Principal Elbaum & Associates Research, Education, and Consultation in Physical Rehabilitation Miami, Florida Modalities Georgianna Gacula Fres, OTR/L Occupational Therapist Hand Therapy All Florida Orthopedic Associates St. Petersburg, Florida Hand Enthusiasts Vendor and Website List Antonio J. Gayoso, MD Plastic Surgery All Florida Orthopaedics Associates St. Petersburg, Florida Flaps/Grafts/Thermal Conditions Casey Hoover, OTR/L Staff Occupational Therapist Hand Therapy All Florida Orthopaedic Associates St. Petersburg, Florida Evaluation, Hand Enthusiasts Vendor and Website List, Nutrition Heather Hoyt, OTR/L Upper Extremity Clinical Specialist Professional Services Otto Bock Health Care Minneapolis, Minnesota Congenital Anomalies/Amputations/Prosthetics Eric P. Keefer, MD Chief Resident Department of Orthopedic Surgery Lenox Hill Hospital New York, New York Biomechanics and Tendon Transfers

Paul C. LaStayo, PhD, PT, CHT Associate Professor Physical Therapy University of Utah Salt Lake City, Utah Wrist Kathryn L. Lowenstein, OTR/L Arthritis Center Palm Harbor, Florida Arthritis Mitchell B. Lowenstein, MD Fellow of the American College of Rheumatology and Internal Medicine Arthritis Center Palm Harbor, Florida Arthritis Anne M. Lucado, MS, PT, CHT Staff Physical Therapist The Hand Center Wake Forest University Baptist Medical Center Winston Salem, North Carolina Tendons Amy Mills, OTR/L, CHT Occupational Therapist All Florida Orthopaedic Associates St. Petersburg, Florida Hand Enthusiasts Vendor and Website List, Nutrition Patrick C. Prigge, CP Upper Extremity Manager Professional Services Otto Bock Health Care Minneapolis, Minnesota Congenital Anomalies/Amputations/Prosthetics Jorge Rodriguez, MD Private Practice St. Petersburg, Florida Elbow

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Contributors Julie A. Schick, CP, OTR/L Clinical Specialist, Upper Extremity Prosthetics Professional Services Otto Bock Health Care Minneapolis, Minnesota Congenital Anomalies/Amputations/Prosthetics Douglas R. Shier, PhD Professor Department of Mathematical Sciences Clemson University Clemson, South Carolina Research and Statistics Stephen D. Simonich, MD Tampa Bay Orthopaedic Specialists St. Petersburg, Florida Sports Injuries of the Upper Extremity Gerald E. Stark, Jr., BSME, CP, FAAOP Guest Lecturer Physical Medicine Prosthetic-Orthotic Center Chicago, Illinois Vice President of Education and Technical Support The Fillauer Companies, Inc. Chattanooga, Tennessee Congenital Anomalies/Amputations/Prosthetics Charlene Stennett, OTR/L, CHT Director of Hand Therapy Miami Hand Center Miami, Florida Fractures Shawn Swanson, BS, OTR/L Occupational Therapist Clinical Specialist, Upper Extremity Prosthetics Professional Services Otto Bock Health Care Minneapolis, Minnesota Congenital Anomalies/Amputations/Prosthetics

Paul Van Lede, OT, MS Orfit Industries Wijnegam, Belgium Splinting Wayne B. Whittle, BS, PT Owner Next Step Rehabilitation St. Petersburg, Florida Elbow S. Steven Yang, MD, MPH Assistant Adjunct Division Hand Surgery Department of Orthopedic Surgery Lenox Hill Hospital New York, New York Biomechanics and Tendon Transfers Contributors to the first edition: Patricia Anderson Brett Bolhofner Arlicia Brown Phyllis J. Bruni Barbara A. Carmen Lisa Rementer Choe Kate Cooper Gail P. Counts Lawrence Gnage Daniel Greenwald Barbara G. Henry Jeri Lynn Houck Jennifer J. Jones King John J. O’Brien, Jr. Scott Raub John M. Rayhack Lori Long Root Sharon Root Spiegel

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To my husband David, for his unconditional support of this project and for losing me for hours on end to edit and re-edit this second edition. Mom and Dad, thanks again for listening to me say how I stayed up late night after night working tediously on each chapter. To Jake my darling little boy for standing next to mommy’s computer every day saying “I love you mommy,” and inspiring me to continue. To Brandon and Justin for allowing me to work in the background with the light on, so I could sit with them while they watched a movie or TV. Finally, I dedicate this book to my dearly loved and missed brother Jason, in loving memory and tears. SW To my precious gifts from God . . . my children David and Danielle. I love you both “to the moon and back” . . . thank you for your unconditional love and support. To the love of my life, Mike Guerra, who has given me love, perspective, and friendship. Mike, you have helped make me whole, when I didn’t know I wasn’t. To my mother, who has given me my “drive” and for her unconditional dedication to me and all her children. NF

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Foreword

In this expanded second edition of Hand Rehabilitation: A Quick Reference Guide and Review, Susan Weiss and Nancy Falkenstein give us a unique approach to critical thinking in hand therapy. In addition to questions relating to specific diagnoses, other areas of clinical practice are included such as anatomy, signs and symptoms, terminology, treatment decisions, use of modalities, and splinting. Unlike many texts that give us sequential information about one subject, this book requires consideration of a wide array of hand therapy information. The question format with multiple choice answers requires the reader to connect theory to real clinical circumstances. With each question being supported by specific references, the reader can conveniently pursue further study of any unfamiliar question or answer. This text is vital for those preparing for the hand therapy certification examination or for those thinking of beginning practice in hand therapy. For those who have already been practicing in the specialty, it is an excellent review. Wrap your brain around this book . . . your clinical reasoning skills will be better for it! Judy C. Colditz, OTR/L, CHT, FAOTA HandLab Raleigh, North Carolina

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Foreword

The term “Purple Book” echoed through the cell phones and e-mails as the must-read book for future CHTs. Not until my partner, Christa Baggott, challenged me to complete a chapter (just before she passed the CHT examination), did I realize the “Purple Book” was the very same book my Florida Hand Society friends, Susan and Nancy, had published 4 years earlier. I erroneously assumed Hand Rehabilitation: A Quick Reference Guide and Review was primarily for pre-CHTs. I took the challenge lightly at first, then seriously. Each question seemed to trigger those cerebral neurons to pull, gather, and blend latent and recent therapeutic knowledge, techniques, and experiences into accessible thoughts. From the commanding voice of my mentor, Dr. William Burkhalter, to a flash of a familiar photo from a landmark article, from a famous quote of Dr. Brands to the texture of a stiff brawny hand, all re-collected then recollected. Self-examination does that. The manuscript of this second edition follows the previously proven test format of the first “Purple Book,” only it is enriched with almost twice the content. Do you know how Eqawa, Jean Duchene, Andre Thomas, Masse, Wartenberg, and Froment’s signs are related? Now describe each one. Like a teen lost in an interactive video game, you will anticipate each topic for the thrill of conquering an upcoming difficult question. Bonuses in the form of Clinical Gems weave a string of pearls that connect one chapter to the next. Right or wrong, there will be a continued satisfaction in settling on a final selection, each not unlike placing that final jigsaw puzzle peace, except the accomplishment is enjoyed repeatedly. Take the challenge, it’s rewarding. Have you kept up with the explosion of information? Since attaining CHT status in 1991, I had questioned the outcome of retaking the CHT examination. Well, the questions in the form of these well-planned pages fulfilled my curiosity. Seasoned therapists should take an earnest approach to this test within a text. It will not only reflect your core knowledge of hand basics, but also be the mirror of proof regarding your continuing education. Cure your curiosity. Susan and Nancy have left personality prints throughout these pages. If you subscribe to their Exploring Hand Therapy newsletter, you are well aware of the wide appeal in the consistency of their casual and concise writing style that also permeates this edition. This appeal is so wide that their first edition spurred quite a competition at the silent auction of the International Federation of Society of Hand Therapists meeting in Scotland this year. Their newly trademarked and timely motto “Treatment to Go” follows their style. This edition, in my opinion is “Knowledge to Go.” Go. Get addicted to the “Purple Book.” Nelson Vazquez, OTR/L, CHT Co-Owner, H.A.N.D.S Rehab Miami, Florida

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Foreword to the First Edition

No doubt Socrates is smiling. In Hand Rehabilitation: A Quick Reference Guide and Review, Nancy Falkenstein and Susan Weiss use a mostly Socratic method—question and answer format—to teach a wide range of topics on hand therapy. In so doing, the authors demonstrate their wealth of knowledge on hand therapy and their skills in teaching hand therapy. They also reveal their creativity and sense of fun. In this long-awaited book, health professionals and students interested in hand therapy will finally have the opportunity to test and enhance their knowledge with a series of structured questions and comprehensive answers. While other disciplines have long enjoyed this format, hand rehabilitation has been without—until now. However, Falkenstein and Weiss go well beyond the basics of question and answer. Each answer includes a well-developed rationale with references in order to bring the reader to a higher level in his or her grasp of the information. With this approach, the authors bring the reader face to face with hand therapy’s core literature. Hand Rehabilitation: A Quick Reference Guide and Review offers a great deal of information and enjoyment for students and health professionals of all levels of expertise. Falkenstein and Weiss have walked the difficult path of incorporating the breadth of hand therapy wisdom—from the basic core concepts (that always seem to need review) to the most esoteric topics. I was thrilled to finally have a name for a sign that I commonly find in my patients but have never seen referenced—despite many years of reading. Who among us is familiar with Linburg’s sign? This is the anatomic interconnection between the flexor pollicis longus and the index finger flexor digitorum profundus that causes the index distal interphalangeal joint to flex when the thumb interphalangeal joint flexes and vice versa. This is only one example of the answers to career-long questions that I found in this text. The authors have carefully sifted through the huge range of hand therapy topics and selected strategic chapters, including evaluation; flaps, grafts, and thermal conditions; wounds and infection; Dupuytren’s disease and tumors; fractures; arthritis; reflex sympathetic dystrophy; tendons; splinting; congenital anomalies, amputations, prosthetics; modalities; cumulative trauma; joint mobilization and other treatment techniques; and several chapters on anatomy. This book covers all commonly seen pathologies, as well as some rarer hand pathologies. It also includes topics usually omitted from texts on hand therapy, and a resource list of vendors offering hand therapy products. I commend Falkenstein and Weiss for including a nutritional quick reference— a topic so critical to excellent outcomes and so often ignored. In keeping with the up-to-date nature of this text, the authors have also included a list of hand therapy–related Internet websites. With such a wellspring of information, no therapist should ever want for references or resources. I predict Hand Rehabilitation: A Quick Reference Guide and Review will be the number one publication sought by therapists studying for the Hand Certification exam. All health professionals and students interested in hand rehabilitation will find this to be a one-of-a-kind, quick xiii

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Foreword to the Firsst Edition

reference text that provides a comprehensive overview. It is well thought out, creatively designed, and packed with the resources we all need as hand rehabilitation professionals. I cannot thank the authors enough for providing the hand therapy community with this book. Karen Schultz-Johnson, MS, OTR, FAOTA, CHT Director, Rocky Mountain Hand Therapy President, UE Tech

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Foreword to the First Edition

Those in the upper extremity rehabilitation world know that it takes a Herculean effort to understand and keep up with massive amounts of information. We are now inundated with books, journals, and web pages. Continuing education and society meetings fill your calendar. So why would I agree to support yet another book on the hand and upper extremity? The reason is simple. This book amplifies and defines the areas of the upper extremity you need to bone up on and reviews the areas you are competent in. This aptitude assessment is easily evaluated with this book. As well, this book is another nice clinical resource that uses a creative and unique format (thank you Nancy Falkenstein and Susan Weiss) to present hand and upper extremity information. At first glance this is a book of test questions and answers on the upper extremity. Although this conjures up images of hours spent reading preparatory books for standardized tests such as the SAT or GRE, there is much more to this book. “Clinical Gems” permeate each chapter and provide easy-to-remember pearls of wisdom regarding various anatomic regions of the upper extremity, specific pathologic states, splinting, modalities, occupational considerations, and research. Answers to the questions are clearly and concisely stated and supplemented with informative illustrations. Quick referencing is made easy through a detailed index at the front of the book. The slide rule helps suppress the desire to check the correct answer before formulating it yourself. Obviously, the structure of this book is designed to aid readers preparing for exams on the upper extremity. There is no other book on the upper extremity available that meets this need, and it serves that purpose extremely well. I hope, however, that readers use it for more than just preparing for “the test.” The format of this book lends itself to self-assessment, which all too often stops once we leave the confines of professional schooling. The exercise of testing yourself is akin to looking at your professional image in the mirror. Is there substance to what you see or is it simply superficial and without state-of-the-art content? This book is the tool for such an assessment. Certainly when areas of weakness are identified, definitive books and specialized journals are essential for in-depth discussion. I’ll never forget how failing a test in school served as a well-defined signal that I had areas of study that needed significant attention. This type of critique should not be limited to your professional education. I encourage all upper extremity rehabilitation professionals to take advantage of this opportunity to assess your level of competence and better define your areas of need. After doing this, read, attend meetings, “surf the net,” question mentors and colleagues, and encourage questions from students. Then combine these academic experiences with the art of treating patients. Good luck and fear not the “test” as it is the test that crystallizes and better defines opportunities for growth. Paul LaStayo, MPT, CHT Northern Arizona University, Department of Biology and DeRosa Physical Therapy, P.C. Flagstaff, Arizona

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Preface

The art and science of asking questions is the source of all knowledge.—Adolf Berle The question-and-answer format of the second edition of Hand Rehabilitation: A Quick Reference Guide and Review provides readers with the unique opportunity to answer questions and the inspiration to ask more. We have written this book to challenge readers to learn and develop a better understanding of the exciting art of hand rehabilitation. We hope that this book will become a premier resource for many individuals in the health sciences, including hand specialists, certified hand therapists, occupational and physical therapists and students, occupational therapy and physical therapy assistants in hand rehabilitation settings, medical and nursing students, physicians, physician assistants, operating room technicians, and orthopedic technicians. This book can be used in a classroom setting or by practitioners who work with or would like to work with patients who have hand or upper extremity disorders. In addition, of course, it is an excellent resource and study guide for professionals preparing for specialty examinations such as the Certified Hand Therapy examination, the Board-Certified Hand Surgery examination, and the Certified Orthopaedic Specialty examination. Students preparing for general registration examinations will also greatly benefit from the selfstudy method presented. This book provides a comprehensive overview of hand rehabilitation through a detailed question-andanswer format that consists of multiple choice, true and false, matching, and fill-in-the-blank questions. Following the question-and-answer choices, we have provided detailed explanations of the correct answer. References, including page numbers, are cited with each question to provide the reader with a simple avenue for further study on a particular subject. In addition, many illustrations have been included to aid in the ease of learning and understanding the topics presented. This

book is designed with a thorough Quick Reference Guide, found at the beginning of the book, to assist the reader in quickly finding information on any topic. A wealth of special features are provided in this book, including Clinical Gems, case studies, a slide rule to aid in self-testing, a list of drugs commonly encountered in hand rehabilitation, nutrition resources, vendors/ website resources, and the addition of a bind-in CDROM that contains the practice questions in a quiz format, allowing the user to perform random self-tests multiple times. We have added two chapters, The Elbow and Sports Injuries of the Upper Extremity, making the book more comprehensive. In addition, we have doubled the information included in the text. There are several different ways to use this text: (1) Readers can review questions and answer explanations as a method of learning the material. (2) The book can be used as a quick reference to access information on a particular topic or clinical problem. (3) Readers can perform self-assessments using the slide rule method, covering up the answer portion with the slide rule provided in the back of the book. (This is part of the back cover and perforated for easy removal.) Readers can take their time to come up with the correct answer and then move the slide rule down to reveal the answer. Readers may want to write their answers on a separate sheet of paper so they can test themselves more than once. (4) Case studies have been used throughout the book to show the reader how content applies to clinical practice. (5) The CD-ROM is used for random testing, allowing you to scramble the questions to test your knowledge. (6) There are four appendixes at the end of the book to use as a quick reference on various subjects. We have included more than 200 Clinical Gems compiled by therapists, physicians, and educators. Clinical Gems range from splinting tips to mnemonics xvii

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Preface

for remembering hand surgery and rehabilitation facts. The Clinical Gems provide invaluable clinical information. This book has been developed through years of experience, preparation for specialty certification, and the desire to learn the art of exploring hand rehabilitation. Through the dedication to learning and teaching we have founded Exploring Hand Therapy, Inc. To learn more about hand therapy, please visit

www.exploringhandtherapy.com and register for our comprehensive newsletter. We have devoted countless hours to preparing and writing this book. Our goal is to provide a quick reference resource that continues to fill a void in hand rehabilitation literature. We developed all of the chapters with the assistance of our contributors who have diverse professional backgrounds. We express our deep appreciation to the contributors for sharing their knowledge.

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Acknowledgments

Susan expressly thanks: • Thank you to Claudette Scott for your hard work, dedication, love you give my son Jake, and friendship. You helped make this project possible for me. • All of our lovely contributors for their time and contributions to this work • The Elsevier staff, including Melissa Kuster, Jennifer Furey, and Kathy Falk, for their time and patience with this project • All Florida Orthopaedics (AFO) for allowing me to grow professionally and for providing me with a wonderful learning environment • The doctors at AFO, including Dale Bramlet, Jorge Rodriquez, and Antonio Gayoso, for teaching me and sharing their patients with me • My lovely friends Ali Goldenfarb, Helen Keys, Roni Murphy, and Jay Kaminsky for their friendship and love • My friend and colleague Dermot Forde for always listening and checking up on me • My co-author Nancy Falkenstein for being my best friend and confidant through it all, and I mean all! We did it again, girl, and my love and gratitude to you is limitless Nancy specially recognizes: • Mark Counts for his dedication to my sister and his family . . . we love you! • Aunt Trish and Uncle Ron for all their direction, input, and love • My brother Chris Falkenstein and sisters Gail Counts and Judy Bain and all my nieces and nephews • Cassey Falkenstein and Keith Bain • Dr. Marvin Susskind for his inspiration and his jokes • My dear friends who have “kept me going,” Nan MacDonald (Alexander), Mandy McCarty, and Nancy Brome • Madlyn Weir, you are my spiritual inspiration, I love your singing and thanks for all your prayers • Jayne Miller for listening to me and lending a friendly “ear” • The contributors for their input and expertise • All my patients present and past. . . . for without them, I would not have excelled • My partner, co-author, and best friend, Susan Weiss. We did it again, girl! I went into this and other projects with you as a partner, and I have gained friendship, wisdom, and retrospection • All the American military for their relentless dedication to Freedom

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1 ANATOMY EXTRAVAGANZA

Chapter 1

Anatomy Extravaganza

A. Lumbrical-plus phenomenon

tunnel and may be a site of ulnar nerve entrapment. The borders of this canal are the hook of the hamate and the pisiform. The median nerve is in the carpal tunnel, not Guyon’s canal.

1. You are treating a patient after flexor digitorum profundus repair to the ring finger. You note that he has a significant reduction of finger flexion force in the digits adjacent to the ring finger. You also recognize a flexion contracture of the ring finger. What might this patient be experiencing?

Answer: A Leclercq, pp. 506-507 Matloub & Yousef, pp. 201-214

Refer to Fig. 1-1

B. Quadrigia phenomenon C. Linburg’s sign D. Egawa’s sign

When a quadrigia phenomenon occurs, the patient exhibits a flexion contracture of the involved digit and a decreased amount of flexion force in the digits next to the injured finger. The quadrigia effect can occur if the flexor digitorum profundus is advanced more than 1 cm during repair, thus resulting in limited proximal excursion of the remaining flexor digitorum profundus tendons. To prevent a quadrigia effect, one should use advancement only for the flexor pollicis longus. Answer: B Hunter, Schneider, Mackin, pp. 423, 428, 595 Culp, Taras in Mackin, Callahan, Skirven, et al, pp. 421-426 Ejeskar, p. 63

2. Which of the following statements about Guyon’s canal is false? A. B. C. D.

Contains the median nerve Contains the ulnar nerve Contains the ulnar artery Borders the hook of the hamate and the pisiform

The ulnar nerve and artery are contained in Guyon’s triangular canal. It is immediately ulnar to the carpal

H

P

C

T L UN

UA

Fig. 1-1

■ Boundaries and contents of Guyon’s canal. C, Capitate; H, hamate; L, lunate; P, pisiform; S, scaphoid; T, trapezoid; TCL, transverse carpal ligament; UN, ulnar nerve; UA, ulnar artery; and VCL, carpal ligament. (From Moneim MS: Ulnar nerve compression at the wrist: ulnar tunnel syndrome, Hand Clin 8(2):338, 1992.)

3. Which of the following statements are true of the anatomical “snuffbox”? A. Lunate forms the floor. B. Abductor pollicis longus and extensor pollicis brevis tendon define the ulnar border. C. Extensor pollicis longus tendon forms the radial border. D. All of the above are true. E. None of the above is true.

1

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2

CHAPTER 1 ■ Anatomy Extravaganza

The anatomical snuffbox is formed by the scaphoid at the base; the abductor pollicis longus and extensor pollicis brevis define the radial border; and the extensor pollicis longus lines the ulnar border. Answer: E Mehta

Refer to Fig. 1-2

4. Protraction—or hunching—of the shoulders is completed by which of the following muscles (pick the most complete answer)? A. Pectoralis major and serratus anterior B. Pectoralis major, serratus anterior, and pectoralis minor C. Pectoralis major, serratus anterior, and anterior deltoid D. Pectoralis major, serratus anterior, anterior deltoid, and pectoralis minor

The large, strong serratus anterior as well as the pectoralis major and minor place the humerus in the “hunched shoulder” or protracted position. Answer: B Bogumill, pp. 1637-1639

Refer to Fig. 1-3

A

L

EP

Fig. 1-3

B EPL

B EP PL

A

Fig. 1-2

CLINICAL GEM: If an individual works all day on a computer or is a computer enthusiast, his or her shoulder protractors are typically shortened and the retractors stretched. Stretching exercises for the protractors, strengthening exercises for the retractors, and postural reeducation are essential. Ergonomic principles for a computer workstation should be addressed.

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A. Median nerve, flexor digitorum profundus, flexor digitorum superficialis B. Median nerve, palmaris longus, flexor digitorum profundus, flexor digitorum superficialis C. Median nerve, flexor pollicis longus, flexor digitorum profundus, flexor digitorum superficialis D. Median nerve, flexor pollicis longus, palmaris longus, flexor digitorum profundus, flexor digitorum superficialis

The carpal tunnel contains ten structures: the median nerve, four flexor digitorum profundus tendons, four flexor digitorum superficialis tendons, and the flexor pollicis longus tendon. The carpal tunnel lies deep to the palmaris longus. Its borders are the pisiform, the scaphoid tubercle, the hook of the hamate, and the trapezium tubercle.

A. B. C. D.

Linburg’s sign Reiter’s syndrome Egawa’s sign None of the above

An anatomic interconnection between the flexor pollicis longus and the index flexor digitorum profundus is present in approximately 31% of the population. The connection may be through an anomalous tendon, musculotendinous slip, or an adherence to the tenosynovium. This anatomic variation is called Linburg’s sign. Linburg’s syndrome can occur when this interconnection leads to pain and aggravation with activity. The discomfort is located over the radiopalmar aspect of the distal forearm and thumb.

5. Which structures run through the carpal tunnel? (Pick the most complete answer.)

3

Answer: A Cooney, Linscheid, Dobyns, p. 1194

Refer to Fig. 1-5

Answer: C Hoppenfeld, p. 83

Refer to Fig. 1-4

Flexor digitorum superficialis (4)

Transverse carpal ligament Median nerve (1)

Flexor digitorum profundus (4)

Flexor pollicis longus (1)

Pisiform Trapezium Hamate Triquetrum Lunate

Scaphoid

Fig. 1-5 ■ Note the flexion of the index finger when active interphalangeal (IP) thumb flexion is performed.

Fig. 1-4

6. What is the anatomic interconnection between the flexor pollicis longus and the index finger flexor digitorum profundus called?

CLINICAL GEM: To assess for Linburg’s sign, have the patient actively flex the thumb interphalangeal joint. Look for involuntary motion at the index finger distal interphalangeal joint.



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4


7. What condition is often present with Linburg’s syndrome? A. B. C. D.

Anterior interosseus syndrome Fracture of the radius Trigger finger Carpal tunnel syndrome

Carpal tunnel syndrome is often present with Lindburg’s syndrome. Lindburg’s syndrome involves tenosynovitis in the flexor pollicis longus and usually includes the flexor digitorum of the index (because of an associated anomalous interconnection). Patients complain of distal (radiopalmar) forearm and hand pain that is aggravated when distal interphalangeal (DIP) flexion of the index is blocked because the thumb is actively flexed into the palm. Answer: D Stern, pp. 467-476

8. What are the primary pathological structures that produce proximal interphalangeal joint flexion contractures?

Volar plate

Check rein ligaments

Fig. 1-6

Compartment 1. 2. 3. 4. 5. 6.

First dorsal wrist compartment Second dorsal wrist compartment Third dorsal wrist compartment Fourth dorsal wrist compartment Fifth dorsal wrist compartment Sixth dorsal wrist compartment

Tendon(s)

Contractures of the proximal interphalangeal joints occur after an unspecified period of time in a negative hand position (intrinsic minus). Thin fibers called swallowtails are extensions of the volar plate at the proximal interphalangeal joint. When these swallowtails become hypertrophied and shortened, they are termed check rein ligaments. Check rein ligaments can develop rapidly after edema occurs or progressively, as in Dupuytren’s contracture.

A. Abductor pollicis longus (APL), extensor pollicis

brevis (EPB) Extensor digiti minimi (EDM) Extensor carpi ulnaris (ECU) Extensor pollicis longus (EPL) Extensor digitorum (ED); extensor indicis proprius (EIP) F. Extensor carpi radialis longus (ECRL); extensor carpi radialis brevis (ECRB) B. C. D. E.

A. Check rein ligaments B. Collateral ligaments of the proximal interphalangeal joint C. Lateral bands D. Oblique retinacular ligaments

Answers: 1, A; 2, F; 3, D; 4, E; 5, B; 6, C Stanley, Tribuzi, p. 9 Miller, p. 544

Refer to Fig. 1-7

Answer: A Green, p. 550

Refer to Fig. 1-6

9. Match the following dorsal wrist compartments with the tendon(s) that reside in each compartment.

CLINICAL GEM: To remember the dorsal compartments, one can recall the numbers 22, 12, and 11. These numbers correlate with the numbers of tendons in each of the six dorsal compartments. Compartment Number of tendons to recall Tendons

1 2

2 2

3 1

4 2

5 1

6 1

EPB APL

ECRL ECRB

EPL EIP

EDC

EDM

ECU

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5

Intertendinous connections

Extensor indicis

Extensor digitorum Extensor digiti minimi Sheath for extensor digitorum and extensor indicis

Extensor pollicis brevis Extensor pollicis longus

Extensor retinaculum

Extensor digiti minimi Extensor carpi radialis longus and brevis

Extensor carpi ulnaris

Extensor pollicis brevis Abductor pollicis longus

■ From Jenkins DB: Linshead’s functional anatomy of limbs and back, ed 6, Philadelphia, 1991, WB Saunders.

CLINICAL GEM: To avoid confusing the fifth and sixth compartments, remember that the tendon to the fifth digit is the extensor digiti minimi (fifth digit equals fifth compartment).

10. True or false: The extensor carpi radialis brevis is the strongest wrist extensor.

The ECRB originates from the lateral epicondyle of the humerus and inserts onto the base of the third metacarpal. The ECRB has the longest extension moment arm and the largest cross-section and is the strongest and most efficient wrist extensor. The ECRL, in contrast, has the longest muscle fibers and the largest mass and therefore has a greater capacity for sustained work. The ECU has the longest moment arm for ulnar

deviation. The ECU becomes a more efficient wrist extensor when the forearm is supinated.

Fig. 1-7

Answer: True Hunter, Mackin, Callahan, p. 523 Rosenthal in Mackin, Callahan, Skirven, et al, p. 502

11. Lateral epicondylitis is a common diagnosis in work-related injuries. Which muscle is primarily affected? A. B. C. D. E.

Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum Extensor carpi ulnaris Brachioradialis

The extensor carpi radialis brevis is the most commonly affected muscle in lateral epicondylitis. It causes pain with passive wrist flexion and active (and resisted) wrist



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6


A

B

■ A, Flexed to 90 degrees for assessment. B, Full extension assessment.

extension. The most tender spot is located 1 to 2 cm distal to the lateral epicondyle. Answer: B De Smet, Fabry, pp. 229-231 Nirschl, pp. 537-552

CLINICAL GEM: Grip testing with the elbow flexed to 90 degrees is less painful for the patient with lateral epicondylitis versus when the grip test is performed with the elbow straight and locked. Most patients with lateral epicondylitis will benefit from education in avoiding provocative motions, such as a forceful grasp and/or lifting with elbow extended and forearm pronated. Refer to Fig. 1-8.

12. Which pulley is most commonly affected in trigger finger? A. B. C. D. E.

A1 A2 A3 A4 A5

pulley pulley pulley pulley pulley

The A1 pulley is the structure that is surgically released when trigger finger is the culprit. Although patients may complain about pain at the PIP joint level, the pathology is at the MP level at the A1 pulley. The A1 pulley can become thickened and narrow from chronic inflammation and will trap the flexor tendon.

Fig. 1-8

Answer: A Hunter, Mackin, Callahan, pp. 1007-1012 Lee, Nassir-Sharif, Zelouf in Mackin, Callahan, Skirven, et al, p. 939

CLINICAL GEM: During trigger finger physical examination, run your finger along the flexor tendons in the palm. Often a nodule is palpable on the flexor tendon just proximal to the MCP joint.

13. Which of the following does not serve as an attachment site for the transverse carpal ligament? A. B. C. D. E.

Scaphoid Trapezium Hamate Triquetrum Pisiform

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7

Answer: False Kimura, p. 418 Tubiana, Thomine, Mackin, p. 277

Refer to Fig. 1-9

16. Match each muscle to the correct description:

Muscle Answer: D Hunter, Mackin, Callahan, pp. 905-906 Hayes, Carney, Wolf, et al, in Mackin, Callahan, Skirven, et al, p. 643

14. What is the best treatment for an acute compartment syndrome? A. Application of ice until swelling subsides B. Active range of motion (AROM) exercises of the affected musculature, followed first by soft tissue massage and then by application of ice pack C. Immediate fasciotomy of all compartments involved D. All of the above

1. 2. 3. 4. 5. 6. 7. 8.

Abductor pollicis brevis Extensor carpi radialis brevis Extensor carpi ulnaris Supinator Extensor pollicis longus Adductor pollicis First volar interosseous First dorsal interosseous

Description A. Strong finger abductor that inserts into the base of

the proximal phalanx of the index finger B. Innervated by the median nerve and originates from

the transverse carpal ligament C. Innervated by the ulnar nerve and inserted into the

Acute compartment syndrome may be caused by crush injury, thermal or electrical burns, snakebite, or fracture. Symptoms include pain, paresthesias, paralysis, and pulselessness. The most telling sign is pain that is out of proportion to a normal pain response and that is not alleviated by rest. Because increasing pressure in the compartment can result in necrosis—which leads to fibrosis of the muscles and other soft tissues—an immediate fasciotomy must be done after the diagnosis is reached.

D. E. F.

G.

Answer: C Naidu, Heppenstall, pp. 13-27 Gellman, Keyur, pp. 385-389

15. True or false: A Martin-Gruber anastomosis is present in 35% to 45% of the population.

H.

ulnar side of the proximal phalanx of the thumb and the extensor expansion of the thumb Inserts into the base of the third metacarpal Innervated by the posterior interosseous nerve (PIN) and inserts into the base of the fifth metacarpal Originates from the lateral epicondyle of the humerus and the adjacent portion of the ulna and inserts into the upper third of the radius Innervated by the posterior interosseous nerve and inserts into the first distal phalanx Originates from the length of the second metacarpal and adducts the index finger

Answers: 1, B; 2, D; 3, E; 4, F; 5, G; 6, C; 7, H; 8, A Malick, Kasch, pp. 57-58, 66

This anomaly is present in 15% to 20% of the population. The Martin-Gruber anastomosis is between the median nerve and the ulnar nerve at the forearm level. The anastomosis usually consists of median-nerve innervated motor fibers that supply the typically ulnarinnervated intrinsics. Ulnar sensory fibers also may be innervated by the median nerve when this anastomosis exists.

CLINICAL GEM: The APB is the strongest muscle of anteposition (opposition). In 1867, Duchenne called the APB muscle the opposing phalangeal muscle of the thumb because of its action on the tip.


The transverse carpal ligament (TCL) attaches to the scaphoid tuberosity, the crest of the trapezium, the pisiform, and the hook of the hamate. The TCL forms the roof of the carpal canal and ranges in thickness from 1 to 3.5 mm. The TCL prevents the long flexors of the fingers from bowstringing when the wrist flexes and serves as an attachment site for thenar and hypothenar muscles.


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8


Anastomosis

Site of injury Anastomosis

Ulnar nerve

Median nerve

Median nerve

Ulnar nerve

Site of injury

Denervated

A

B

Fig. 1-9 ■ A, A high ulnar nerve lesion in which the anastomosis from the median to ulnar nerve occurs distal to the injury and prevents paralysis of the ulnar innervated intrinsics. B, A low ulnar nerve injury distal to the anastomosis, which causes paralysis of the ulnar innervated digits.

17. The elbow’s main stabilizer to valgus strain is which of the following? A. B. C. D.

Medial epicondyle Medial collateral ligament Lateral epicondyle Lateral collateral ligament

The medial (ulnar) collateral ligament (UCL) is the main stabilizer of the elbow joint and prevents valgus strain. The UCL originates slightly anterior and inferior to the medial epicondyle. It fans out to its attachment along the greater sigmoid fossa. It comprises anterior, posterior, and transverse bands. Damage to the UCL usually necessitates surgery.

hyperextend the metacarpophalangeal (MCP) joints during finger extension. However, stabilization and prevention of hyperextension of the MCP joint (placing and holding the MCP in slight flexion) during extension can transfer the force from the long extensors to the PIP and DIP joints, thus resulting in extension. Which test was just described?

Answer: B Morrey, pp. 549-551

Refer to Fig. 1-10

18. With paralysis of the interosseous muscles, the long finger extensors are unopposed. They

A. B. C. D.

Tinels Bouvier Adsons Finochietto-Bunnell

Bouvier is the test described and is used to determine whether the PIP joint capsule and extensor mechanism are working normally. In cases of claw hand deformity (interosseous muscle palsy), if the MCP joints are stabilized and prevented from going into hyperextension, the intrinsic muscle force is transferred distally to the PIP and DIP joints, thus aiding in reestablishing PIP and DIP extension.

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9



A

B Fig. 1-10 ■ A, Lateral view of the bony and ligamentous anatomy of the elbow joint. B, Left, Laxity of the radial collateral ligament (varus instability of the elbow) is examined with the humerus in full internal rotation while varus stress is applied to the joint. Right, Laxity of the medial collateral ligament (valgus instability of the elbow) is evaluated with the humerus in full external rotation as valgus stress is applied to the joint. In both instances, rotation helps stabilize the humerus, allowing ligament laxity to be more easily appreciated. (A, From Mackin EJ, Callahan AD, Skirven TM, et al: Rehabilitation of the hand and upper extremity, ed 5, vol 1, St Louis, 2002, Mosby; B, from Morrey BF: The elbow and its disorders, ed 2, Philadelphia, 1994, WB Saunders.)

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10


A

B

Fig. 1-11

Answer: B Tubiana, Thomine, Mackin, pp. 109-110, 223

Refer to Fig. 1-11

A5

CLINICAL GEM: When splinting, remember this principle to prevent claw hand deformity following paralysis of the interosseous muscles.

19. True or false: The most important pulleys in the flexor tendon system are A3 and A5.

Pulleys ensure biomechanical efficiency of the flexor tendons. Their role is to prevent bowstringing of the tendons and to allow the flexors to work efficiently. Each finger has five annular pulleys and three cruciate pulleys. A2 and A4 are the most important pulleys in the flexor tendon system. Answer: False Malick, p. 43

Refer to Fig. 1-12

A3 A4

A1 A2

Fig. 1-12

CLINICAL GEM: An easy way to remember the pulleys is to recall that the odd numbers for the annular pulleys correlate with finger joints: MPJ—A1 PIPJ—A3 DIPJ—A5

20. Wallbangers’ disease refers to persistent hard edema over the dorsum of the hand. The inexplicable edema usually occurs after a minor hand injury. This is more typically known by which of the following terms?

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A. B. C. D.

SHAFT syndrome Munchausen syndrome Clenched-fist syndrome Secretan’s syndrome

11

Superior ulnar collateral a. Inf. ulnar collateral a. Brachial a. Volar ulnar recurrent a.

Secretan’s syndrome (Wallbangers’ disease) is a psychological condition that results in self-infliction of harm and exacerbation of symptoms to prolong the illness/ disorder.

Recurrent radial a.

Answer: D

Dorsal ulnar recurrent a.

Flexor digitorum profundus m.

Kasdan, pp. 57-60

Flexor pollicis longus m.

CLINICAL GEM: Remember the S’s: self-inflicted/Secretan’s syndrome.

Median n. and a.

21. What is the major arterial supply to the forearm and hand? Radial artery Brachial artery Median artery Interosseous artery

The brachial artery continues from the axillary artery and travels distally along the medial arm. The median nerve is nearby. At the antecubital fossa, the brachial artery dives below the lacertus fibrosis and splits into the radial and ulnar arteries. The brachial artery is the major inflow vessel to the forearm and hand. Answer: B Spinner, p. 203

Refer to Fig. 1-13

22. How long do blood vessels require protection after surgical repair? A. B. C. D.

1 to 5 days 7 to 14 days 14 to 21 days 21 to 28 days

Radial a.

Radial a., superficial volar br.

Ulnar a. and n. Transverse carpal ligament

Fig. 1-13 ■ From Mackin EJ, Callahan AD, Skirven TM, et al: Rehabilitation of the hand and upper extremity, ed 5, vol 1, St Louis, 2002, Mosby.

Blood vessels require 1 to 2 weeks of protection. This is generally provided by the immobilization needed to protect other structures that are repaired.

A. B. C. D.

Answer: B Hunter, Mackin, Callahan, p. 1059

23. What is the combined function of Cleland’s and Grayson’s ligaments? A. B. C. D.

Prevents Dupuytren’s contracture Stabilizes the metacarpophalangeal joint Stabilizes the basal joint Prevents rotary movements of the skin around the fingers



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Grayson’s ligament originates from the volar aspect of the flexor tendon sheath, runs volar to the neurovascular bundle, and inserts into the skin. Cleland’s ligament passes dorsally to the neurovascular bundle and inserts into the skin. According to Hoppenfeld, both Grayson’s and Cleland’s ligaments prevent rotary movement of the skin around the fingers, thus allowing the ability to grasp objects. Grayson’s ligament may contribute to a PIP joint flexion contracture in Dupuytren’s disease. Answer: D Hoppenfeld, p. 65 Green, pp. 564-565

Refer to Fig. 1-14

A. B. C. D.

Radial artery Ulnar artery Persistent median artery All of the above arteries supply the hand equally

The ulnar artery is larger than the radial artery and is usually the primary contributor, supplying 60% of blood to the hand. This artery supplies the superficial palmar arch in most hands, and the radial artery usually supplies the deep palmar arch. The median artery contributes to the superficial palmar arch in approximately 10% of the population. Variation in the superficial arch is greater than in the more consistent deep palmar arch. In general, arterial variations occur in up to a third of the population.

CLINICAL GEM: Cleland’s ligaments are dorsal to the neurovascular bundle. To remember this, recall that “C” for Cleland precedes “D” for dorsal.

24. Which artery provides the primary blood supply to the hand?

Answer: B Anderson, Sec. 6-78

Refer to Fig. 1-15

Grayson’s ligament

Cleland’s ligament

Superficial palmar arch

Princeps pollicis artery Deep palmar arch

Ulnar artery

Fig. 1-14

Fig. 1-15

Radial artery

■ From Smith AA, Lacey SH: Hand surgery review, St Louis,

1996, Mosby.

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1. 2. 3. 4. 5. 6.

Adductor pollicis Brachioradialis Extensor indicis proprius Palmaris brevis Abductor pollicis brevis Pronator quadratus

Innervation

A. B. C. D. E. F.

Superficial branch of ulnar nerve Deep branch of ulnar nerve Posterior interosseous nerve Anterior interosseous nerve Median nerve Radial nerve

Answers: 1, B; 2, F; 3, C; 4, A; 5, E; 6, D Hunter, Mackin, Callahan, pp. A1-A40 Malick, pp. 57-66

26. Sensory changes, motor changes, and atrophy of the thenar musculature may indicate which of the following? A. B. C. D.

Muscle

Two to three millimeters per month of nail growth is the expected growth rate. Thus the nail can provide a fairly accurate timetable of systemic insults, whether from toxic substances or disease. Answer: B Tubiana, Thomine, Mackin, p. 5

28. During “normal” flexing into a fist, the fingers converge and point toward what structure? A. B. C. D.

Hook of the hamate Tubercle of the trapezium Base of the first metacarpal Scaphoid tubercle

The scaphoid tubercle is the point of finger convergence when a fist is made. When the digits flex into a digitopalmar grip, the more ulnar the digit, the more obliquely it deviates as it comes into the palm. Thus with each digit flexed at the MCP and PIP joints, their axes converge toward the scaphoid bone.

25. Match each muscle with its innervation.

13

Answer: D Tubiana, Thomine, Mackin, p. 6 Weinzweig, p. 13

Refer to Fig. 1-16

Syringomyelia Peripheral neuritis secondary to diabetes Lead intoxication Charcot-Marie-Tooth disease

Individuals with diabetes may complain of sensory and motor changes and have evidence of thenar muscle atrophy. It may be confused with carpal tunnel compression of the median nerve at the wrist. In fact, carpal tunnel syndrome may coexist in persons with diabetes. Answer: B Tubiana, p. 16

27. Fingernails generally grow at what rate per month? A. B. C. D.

1 2 3 4

to to to to

2 mm 3 mm 4 mm 5 mm

per per per per

month month month month

Fig. 1-16 ■ From Weinzweig J: Hand and wrist surgery secrets, Philadelphia, 2000, Hanley & Belfus.



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14

29. Which structure plays a crucial role in the stability of the shoulder? Teres major Glenoid labrum Long head of the biceps Coracoacromial ligament

A. B. C. D.

Answer: A Taleisnik, p. 67 Green, p. 824

31. Which of the following statements is false with regard to the metacarpophalangeal (MCP) joint collateral ligaments? A. With the MCP joint extended, the collateral liga-

The stability of the glenohumeral joint is sacrificed because of its great freedom of movement. The humeral head articulates against the glenoid cavity of the scapula. The labrum is important because it gives the glenoid a deeper cavity, thus allowing for increased surface area and stability. The head of the humerus is held in the glenoid cavity by the rotator cuff muscles. The glenoid labrum is a fibrocartilaginous rim that is attached around the margin of the glenoid process.


ments are loose, and the portion from the metacarpal to the palmar plate is taut. B. With the MCP joint flexed, the collateral ligaments are tight, and the portion from the metacarpal to the palmar plate is lax. C. This structure allows for lateral movement during MCP extension and prohibits lateral movement during flexion. D. This information is not important to consider when one splints the MCP joints.

The information in A through C is vital when splinting the MCP joints. Splinting the MCP joints in extension for prolonged periods tightens the MCP joint collateral ligaments into a shortened position.

Answer: B Netter, p. 34

Refer to Fig. 1-17 Acromion Clavicle

Glenoid surface

Boscheinen-Morrin, Conolly, pp. 3-5.

Refer to Fig. 1-18

Supraspinatus tendon Acromioclavicular ligament

Answer: D

Humerus

Deltoid

Glenoid labrum

Fig. 1-17

30. Which pole of the scaphoid has a generous blood supply? A. B. C. D.

Distal pole Waist Proximal pole All of the above have excellent vascularity.

The scaphoid most often receives its arterial blood supply from the radial artery through ligamentous attachments. The distal pole has a rich blood supply and tends to heal promptly, whereas the proximal pole has poor vascularity and may result in avascular necrosis or nonunion after fracture.

Fig. 1-18

■ From Jupiter JB: Flynn’s Hand surgery, ed 4, Philadelphia, 1991, Williams & Wilkins.

32. Identify the following features (1-7) of the dorsal aspect of the hand in Fig. 1-19. A. B. C. D. E. F. G.

Abductor pollicis longus (APL) Juncturae tendinum Dorsal tubercle of the radius/Lister’s tubercle Extensor pollicis longus (EPL) Tendon to extensor carpi radialis longus (ECRL) Extensor retinaculum Extensor digitorum

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15

34. Label the creases (1-8) of the hand and wrist in Fig. 1-20 with the following terms. Thenar crease Proximal crease of the wrist Distal crease of the wrist Proximal flexor crease (proximal palmar crease) Distal flexor crease (distal palmar crease) Palmar digital crease Proximal interphalangeal crease (middle digital crease) H. Distal interphalangeal crease (distal digital crease) A. B. C. D. E. F. G. 5

3

4

Answers: 1, E; 2, A; 3, F; 4, B; 5, H; 6, C; 7, D; 8, G Chase in Mackin, Callahan, Skirven, et al, p. 64

2 6 7

35. Which nerve and artery pass through the quadrangular space?

1

A. Musculocutaneous nerve and posterior circumflex

artery B. Axillary nerve and posterior circumflex artery C. Musculocutaneous nerve and anterior circumflex

artery D. Axillary nerve and anterior circumflex artery

Answers: 1, C; 2, E; 3, A; 4, D; 5, B; 6, G;

7, F Boscheinen-Miller, Conolly, p. 44

33. Which two muscles line the medial and lateral borders of the cubital fossa? A. B. C. D.

Biceps medially and brachioradialis laterally Brachioradialis laterally and pronator teres medially Pronator teres laterally and brachioradialis medially Flexor carpi ulnaris medially and biceps ulnarly

The quadrangular space is bordered by the teres minor superiorly, the teres major inferiorly, the humerus laterally, and the triceps medially. The axillary nerve and posterior circumflex artery pass through this space.

Fig. 1-19 ■ Copyright Elizabeth Roselius. Green DP, Hotchkiss RN, Pederson WC: Green’s Operative hand surgery, ed 4, Philadelphia, 1999, Churchill Livingstone.

Answer: B Netter, p. 24

Refer to Fig. 1-21

36. Which artery passes over the floor of the anatomic snuffbox? A. B. C. D.

Radial artery Ulnar artery Median artery Anterior interosseous artery

The brachioradialis forms the lateral border, and the pronator teres forms the medial border of the cubital fossa. Answer: B Hunter, Mackin, Callahan, p. 46 Mackin, Callahan, Skirven, et al, p. 29 Morrey, p. 67 Omer in Mackin, Callahan, Skirven, et al, p. 676

The anatomic snuffbox is a concave space made by the convergence of the extensor pollicis longus tendon with the extensor pollicis brevis and the abductor pollicis longus tendons. On the floor, the radial artery passes toward the back of the hand to the dorsal carpal branch.



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5

3

8

2 1

7

6

4

■ From Jupiter JB: Flynn’s Hand surgery, ed 4, Philadelphia, 1991, Williams & Wilkins.

Fig. 1-20

Axillary nerve Posterior humeral circumflex artery

Axillary artery

Answer: A Netter, p. 60

CLINICAL GEM: Tenderness in the snuffbox may indicate a scaphoid fracture.

Quadrangular space Triangular space

Teres minor

Circumflex scapular artery

Teres major

Long head of triceps

37. In the forearm, at the level of the elbow, which three veins make the M shape? A. Median cubital vein, basilic vein, and lateral cuta-

neous vein B. Basilic vein, cephalic vein, and median cubital vein C. Cephalic vein, lateral cutaneous vein, and basilic

vein D. None of the above

Fig. 1-21


1996, Mosby.

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Definitions A. An adventitious sound heard on auscultation and of

venous or arterial origin B. An abnormal tremor that accompanies a vascular or

cardiac murmur felt on palpation Answer: B

C. Localized abnormal dilation of a blood vessel,

Hunter, Mackin, Callahan, p. A-17 Hunter in Mackin, Callahan, Skirven, et al, p. 19

Refer to Fig. 1-22

usually an artery D. A benign tumor of dilated blood vessels E. A sensitive noninvasive technique for determining

Lat. brachial cutaneous nerves upper

blood flow

Answers: 1, B; 2, A; 3, C, 4, E; 5, D Taber’s Cyclopedic Medical Dictionary

39. What is the space of Poirier?

Lat. brachial cutaneous n., lower Medial brachial cutaneous n.

Basilic v. Medial antibrachial cutaneous n. Lat. antibrachial cutaneous n. Median cubital v.

A gap between the scaphoid and lunate bones An area of avascularity in the scaphoid Weakness from an absence of ligamentous support T-shaped ligaments over the hamate and triquetrum

A. B. C. D.

The volar wrist capsule often contains an area of weakness called the space of Poirier. This weakness is caused by the absence of a volar lunocapitate ligament. Some authors report that this lack of ligament support causes wrist instability.

Cephalic v. Intercostobrachial n.

Answer: C Taleisnik, p. 25

Refer to Fig. 1-23

Post. antibrachial cutaneous n. Basilic v. Cephalic v.

Fig. 1-22

Hook of hamate

Radiocapitate ligament

Capitotriquetral ligament

Radiocollateral ligament

Space of Poirier

■ From Mackin EJ, Callahan AD, Skirven TM, et al: Reha-

Radiotriquetral ligament

bilitation of the hand and upper extremity, ed 5, vol 1, St Louis, 2002, Mosby.

Fig. 1-23

38. Match the following vascular terms with the correct definitions. Terms 1. 2. 3. 4. 5.

Thrill Bruit Aneurysm Doppler echocardiography Hemangioma


1996, Mosby.

40. Blood supply to the thumb comes primarily from which of the following? A. B. C. D.

The The The The

superficial branch of the ulnar artery deep branch of the radial artery superficial branch of the radial artery deep branch of the ulnar nerve


The cephalic vein that runs on the lateral (radial) aspect of the upper extremity and the basilic vein that travels along the medial (ulnar) upper extremity form an M shape with the median cubital vein at the elbow.

17

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18


tion. In general, slight elevation above the heart is beneficial for venous stasis, and slight lowering below the heart is helpful for arterial system management.

Answer: B Hunter, Mackin, Callahan, pp. 34-35

The deep branch of the radial artery provides the primary blood supply to the thumb.

41. Place the correct nerve innervation next to the muscle.

Answer: D Hunter, Mackin, Callahan, pp. 1059, 1092 Pettengill in Mackin, Callahan, Skirven, et al, pp. 1413-1418

43. What is the lacertus fibrosus? Key 1. Radial nerve = R 2. Median nerve = M 3. Ulnar nerve = U

A. B. C. D.

Part of the arcade of Frohse Continuation of the arcade of Struthers The ligament of Struthers Synonymous with the bicipital aponeurosis

Muscle

Extensor pollicis longus Extensor pollicis brevis Abductor pollicis longus Abductor pollicis brevis Adductor pollicis Flexor pollicis longus Flexor pollicis brevis Volar interossei Dorsal interossei Lumbricals II and III Lumbricals V and IV

The lacertus fibrosus is another name for the bicipital aponeurosis. It is a fibrous band that originates from the tendon of biceps brachii. The lacertus fibrosus is tightened with pronation. Active flexion of the elbow in conjunction with pronation may contribute to compression of the median nerve at the lacertus fibrosus.

A. B. C. D. E. F. G. H. I. J. K.

Answer: D Green, pp. 1342-1343

Refer to Fig. 1-24

Answer: A, R; B, R; C, R; D, M; E, U; F, M;

G, M; H, U; I, U; J, M; K, U Omer, Spinner, Van Beek, pp. 42-47

Refer to Table 1-1

Lacertus fibrosus

42. Which of the following is not a sign of arterial insufficiency? A. B. C. D.

Pallor Decreased temperature Sluggish capillary refill Cyanosis Biceps

Arterial insufficiency results in pallor (lack of color), decreased temperature, increased pain, slow capillary refill, and loss of pulse. Venous insufficiency is recognized by cyanosis (bluish discoloration of the skin caused by reduced amounts of hemoglobin in the blood) and abnormal capillary refill. Excessive elevation above the level of the heart can stress the arterial system during the acute phase and should be avoided. Elevation at the level of the heart is the recommended posi-

Pronator teres

Brachial artery

Fig. 1-24

Median nerve

Pronator teres, pronator quadratus, flexor carpi radialis, palmaris longus, flexor palm and radial fingers profundus (second and third), flexor pollicis longus, abductor pollicis brevis, flexor pollicis brevis (superficial head), opponens pollicis, lumbricales (first and second) Flexor carpi ulnaris, flexor pollicis brevis (deep head), flexor digitorum profundus (fourth and fifth), flexor digiti minimi brevis, opponens digiti minimi, palmaris brevis, adductor pollicis, flexor pollicis brevis, abductor digiti, lumbricales (third and fourth), interossei

Anterior interosseous Recurrent motor branch Palmar cutaneous

Superficial palmar


Pulp of little finger, dorsal ulnar surface of hand, ulnar palm, and ulnar fingers

Pulp of thumb and index, proximal palm and thenar eminence, radial

Ulnar forearm

Dorsal distal upper arm Dorsal radial forearm Dorsal first web space Radial dorsum of hand, wrist joint

Sensory distribution None None None None None None None None Over deltoid, lateral aspect of upper arm, lateral portion of shoulder joint Volar radial forearm to wrist; may extend to thenar eminence Medial aspect of upper arm


From Omer GE, Spinner M, Van Beek AL: Management of peripheral nerve problems, ed 2, Philadelphia, 1998, Saunders.

Italics: Key muscles, most reliable sensory distribution.

Ulnar, C8-T1

Medial antebrachial cutaneous, C8-T1 (medial cord) Median, C5-T1

Anterior ulnar

Triceps brachii, brachioradialis, anconeus, extensor carpi radialis (brevis and longus), extensor digitorum communis II-V, brachialis, supinator, extensor carpi ulnaris, extensor digiti minimi, extensor pollicis longus, extensor pollicis brevis, extensor indicis proprius None

Posterior interosseous Posterior, brachial, cutaneous, antebrachial, cutaneous, superficial, radial

Medial brachial cutaneous (medial cord) C8-T1 Radial, C5-C8

Biceps brachii, brachialis, corocobrachialis (together with radial nerve), pronator teres None

Lateral antebrachial cutaneous

Musculocutaneous, C5-C7

Muscle innervation Rhomboid major, rhomboid minor, levator scapulae Supraspinatus, infraspinatus Subclavius Teres major Serratus anterior Latissimus dorsi Pectoralis major, pectoralis minor Pectoralis major, pectoralis minor Deltoid, teres minor

Lateral, brachial, cutaneous

Branch

Nerves Dorsal scapular, C4-C5 Suprascapular, C4-C6 Nerve to subclavius, C5 Subscapular, C5-C7 Long thoracic, C5-C7 Thoracodorsal, C6-C8 Lateral pectoral, C6 Medial pectoral, C7-C8 Axillary, C5-C6

Upper Extremity: Motor and Sensory Nerve Contribution to Peripheral Nerves

Table 1-1

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19

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20


Terms 1. 2. 3. 4. 5.

Fascia Muscle Sprain Strain Erythematous

The basilic vein joins the brachial vein at the lower border of the teres major and goes on to form the axillary vein. The axillary vein is termed the subclavian vein at the first rib.

44. Match the following terms with the correct definitions.

Answer: A Hunter, Mackin, Callahan, p. A12

Refer to Fig. 1-25

Definitions

Ant. and post. circumflex humeral veins

A. Injury to the joint with ligamentous damage B. Injury to the muscle or musculotendinous unit C. A fibrous membrane that covers, supports, and

separates muscles D. A type of tissue composed of contractile fibers E. Dry, pink patches of skin that are itchy and burn

Axillary v. Supreme thoracic v.

Basilic v. Brachial veins

Answers: 1, C; 2, D; 3, A; 4, B; 5, E

Lateral thoracic v.

Taber’s Cyclopedic Medical Dictionary Thoracodorsal v.

A. B. C. D. E.

Pronator quadratus Flexor carpi radialis Flexor digitorum superficialis Flexor carpi ulnaris Pronator teres

Muscles originating from the common flexor origin include the pronator teres, flexor carpi radialis, flexor digitorum superficialis, palmaris longus, and flexor carpi ulnaris. Pronator quadratus is a distal forearm muscle that originates from the distal ulna. Answer: A Hoppenfeld, de Boer, p. 102

46. The basilic vein and the brachial vein form which vein? A. B. C. D.

Axillary vein Cephalic vein Thoracoepigastric vein Thoracodorsal vein

Thoracoepigastric v.

Subscapular v. Costoaxillary veins


47. True or false: All vein grafts should be marked and reversed when they are used in arterial reconstruction.

Both veins and arteries have been used for interposition grafts and microsurgery, but venous grafts are more readily available and appear to have the highest patency rate. All vein grafts should be marked and reversed when they are used in arterial reconstruction because even the smallest digital vessels have been shown to contain valves. Veins have valves that prevent backward circulation; therefore if veins are not reversed, blood will not flow properly.

45. Which of the following muscles does not originate from the common flexor origin on the medial epicondyle of the humerus?

Cephalic v. Thoraco– acromial vein

Answer: True Green, p. 1061

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A. B. C. D.

A1 pulley Oblique pulley A2 pulley Pulleys are not important in the thumb.

The oblique pulley, which is located in the mid-portion of the proximal phalanx, is the most important pulley. The pulley system in the thumb comprises the A1 pulley located at the MCP joint level, the oblique pulley at the mid-portion of the proximal phalanx, and the A2 pulley located at the IP joint. IP joint motion in the thumb will decrease if the oblique pulley is damaged. Answer: B Hunter, Mackin Callahan, p. 418 Chase in Mackin, Callahan, Skirven, et al, p. 69

Answer: C Hunter, Mackin, Callahan, p. 633

50. Lister’s tubercle is a bony prominence located on which of the following? A. B. C. D.

Scaphoid Proximal ulna Distal radius Distal ulna

Lister’s tubercle is located on the distal radius. The extensor pollicis longus (EPL) takes a 45-degree turn around Lister’s tubercle, which acts as a pulley on its course to the thumb. Rupture of the EPL is not uncommon in patients with rheumatoid arthritis. The EPL may rupture after a distal radius fracture if the tubercle is disrupted.

Refer to Fig. 1-26

21

Thumb pulleys


CLINICAL GEM: The SL ligament can be palpated approximately 1 cm directly distal to Lister’s turbercle on the distal radius.

Annular

Oblique Annular

51. Which structure articulates with the cupped surface of the proximal radius? Fig. 1-26

■ From Chase RA: Atlas of hand surgery, vol 2, Philadelphia, 1984, WB Saunders.

A. B. C. D.

49. Which muscle’s function would be affected by a lesion of the posterior interosseous nerve? Brachioradialis Extensor carpi radialis brevis Extensor digitorum All of the above

The capitulum is spherical and smaller than the trochlea. The capitulum articulates with the cupped surface of the radius (radial head). The trochlea is shaped like a spool and is superior to the coronoid fossa.

A. B. C. D.

The extensor digitorum communis is affected as the deep branch of the radial nerve innervates the extensor digitorum communis, abductor pollicis longus, extensor pollicis longus, and extensor pollicis brevis.

Trochlea Coronoid Capitulum Medial epicondyle

Answer: C Netter, p. 31

Refer to Fig. 1-27


48. Which thumb pulley is the most important?


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22


53. Which muscle is not included in the wad of Henry? A. B. C. D.

Humerus

Brachioradialis Supinator Extensor carpi radialis brevis Extensor carpi radialis longus

Trochlea

Radial head Coronoid process

Ulna

Hoppenfeld describes the brachioradialis, extensor carpi radialis brevis, and extensor carpi radialis longus as “the mobile wad of Henry” or “mobile wad of three.” These muscles are best palpated as a unit, which is easily held and moves between the fingers. One can assess this group of muscles when the patient’s forearm and wrist are in the neutral position. The supinator is not part of the wad of Henry.

Capitulum

Answer: B Hoppenfeld, p. 47

Refer to Fig. 1-28

Fig. 1-27

52. Match each muscle with the correct insertion. Muscle 1. 2. 3. 4. 5.

Subscapularis Pectoralis major Coracobrachialis Brachialis Supraspinatus

Insertion

A. B. C. D. E.

Bicipital groove Coronoid process of ulna Greater tubercle of humerus Shaft of humerus Lesser tubercle of humerus

Answers: 1, E; 2, A; 3, D; 4, B; 5, C Hunter, Mackin, Callahan, pp. 16-18 Hunter in Mackin, Callahan, Skirven, et al, pp. 20-22

Fig. 1-28

■ Mobile wad of Henry.

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54. Match each plane with the correct definition. Plane 1. 2. 3. 4.

Coronal plane Frontal plane Sagittal plane Transverse plane

23

The oblique retinacular ligament (ORL) was described by Landsmeer in 1949. This ligament coordinates the movement of the interphalangeal joints. The functional value of this ligament is controversial in normal fingers but evident in pathological conditions. The ORL is taut in DIP joint flexion; therefore if this ligament is contracted in extension, the DIP joint is not able to fully flex. When the ORL is contracted, it contributes to the boutonniere deformity.

A. Another name for coronal plane B. Divides the body into superior and inferior portions

Definition

at right angles to the long axis of the body C. Divides the body into right and left parts; called the

Answer: A Aulicino in Mackin, Callahan, Skirven, et al, p. 133 Hunter, Mackin, Callahan, p. 65 Tubiana, Thomine, Mackin, p. 103

Refer to Fig. 1-29

median plane D. Divides the body into front and back portions

Answers: 1, D; 2, A or D; 3, C; 4, B Putz-Anderson, p. 116

55. Which of the following statements is false with regard to the blood supply to the hand?

Statement A is an incorrect or false statement because it states that the blood supply to the hand depends on arterial pressure, not venous pressure. Answer: A Smith, p. 35

56. Landsmeer’s ligament is another term for which structure? A. B. C. D.

The oblique retinacular ligament The transverse retinacular ligament The triangular ligament Cleland’s ligament

Fig. 1-29

57. True or false: A ligament attaches a muscle to a bone.

A ligament is a band or sheet of strong, fibrous, connective tissue that connects the articular ends of bones; it binds them together and facilitates or limits motion. A tendon is a fibrous, connective tissue that attaches muscle to bone.

A. The supply of blood to the hand depends on the venous pressure. B. The arterial system, which brings blood into the hand, is situated on the volar aspect of the hand. C. The venous and lymphatic system, which returns blood back into the system, is located dorsally. D. The return flow through the veins and lymphatics normally depends on active movement of the hand and arm, which acts as a pumping mechanism.

Oblique retinacular ligament

Answer: False Taber’s Cyclopedic Medical Dictionary

58. A fingerprint is made from which of the following? A. B. C. D.

Reticular dermis Skin bulging Papillary ridges Oil in the fingertips



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24


Answer: C

59. Which of the following is the term for the white area at the base of the fingernail? A. B. C. D.

Hyponychium Eponychium Paronychia Lunula

Tubiana, Thomine, Mackin, p. 131

Refer to Fig. 1-30

The lunula is the white convex area seen at the base of the nail. The hyponychium is under the nail bed. The eponychium is the embryonic structure from which the nail develops. A paronychia is an acute or chronic infection around the nail. Answer: D Tubiana, Thomine, Mackin, p. 151 Taber’s Cyclopedic Medical Dictionary

60. Results of Allen’s test are considered abnormal when the reflow into all or part of the hand takes longer than what amount of time? A. B. C. D.

1 3 5 7

second seconds seconds seconds

A

7 seconds is the baseline to determine latent reflow. Slowness of more than 7 seconds indicates inadequate flow due to obstruction or anomaly. The Allen’s test can also be used to assess digital flow. Testing to measure return of flow can be supplemented by laser Doppler flowmetry and pressure manometry.

Fingerprints are formed from cutaneous striations that are reflective of organized papillary ridges in the underlying dermis. The reticular dermis is incorrect because it is a deeper layer that comprises collagen and elastic fibers.

Answer: D Kasdan, Amadio, Bowers, p. 282 Aulicino in Mackin, Callahan, Skirven, et al, pp. 140-141

Refer to Fig. 1-31

61. Pain is present in approximately two thirds of patients with upper extremity vascular disease. Match the cause of vascular disease–related pain with the appropriate symptoms. B Cause

Fig. 1-30

■ B, Papillary ridges.

A. B. C. D.

Sudden arterial occlusion Vasospasm Obstructive arterial problem Severe arterial insufficiency

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25

1. 2. 3. 4. 5.


62. Label Fig. 1-32. Distal phalanx Hyponychium Nail bed Eponychium Nail plate

A D A

B

E

C

Allen’s test: radial and ulnar artery

Fig. 1-32

■ Modified from Smith AA, Lacey SH: Hand surgery review, St Louis, 1996, Mosby.

B

Answers: 1, E; 2, A; 3, C; 4, D; 5, B Green, p. 1283

63. The palmaris longus is absent in what percent of the population?

Fig. 1-31

Symptoms Pain with exertion that is alleviated by rest Mild paresthesias and marked pallor Severe pain with sudden onset Pain at rest

Answer: A, 3; B, 2; C, 1; D, 4 Hunter, Mackin, Callahan, pp. 961-962 Taras, Lemel, Nathan in Mackin, Callahan, Skirven, et al, pp. 882-883

30% to 40% 5% to 8% 13% to 20% 75% to 85%

The palmaris longus is absent in 13% to 20% of the population. It originates from the medial epicondyle of the humerus and inserts into the palmar aponeurosis. The palmaris longus tendon is easily detected as it courses over the transverse carpal ligament. This tendon often is sacrificed when tendon transfers are performed.

1. 2. 3. 4.

A. B. C. D.

Answer: C Hunter, Mackin, Callahan, p. 26 Chase in Mackin, Callahan, Skirven, et al, p. 62

64. The fingernails of digits two and three receive their sensation from which nerve?

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26 A. B. C. D.


Median nerve Ulnar nerve Radial nerve Anterior interosseous nerve

As the proper digital nerves pass toward their destination in the pad of the finger, they give off branches for the innervation of the skin on the dorsum of the fingers and matrices of the fingernails. Digital nerves for the first, second, third, and half of the fourth fingers are median nerve–innervated. Answer: A Netter, p. 58

65. The “attitude” of the hand in Fig. 1-33, A, depicts which of the following? A. B. C. D.

Position of rest Lumbrical plus position Intrinsic minus position Intrinsic plus position

A

The “attitude” of the hand is an important factor to evaluate. The position of rest occurs when the metacarpophalangeal joints and the interphalangeal joints are slightly flexed and the fingers line up almost parallel to each other (Fig. 1-33, A). If one finger is extended (perpendicular to the others), its flexor tendon may have been damaged (Fig. 1-33, B). Answer: A Hoppenfeld, p. 61

66. Which of the following would patients with vascular disease not experience? Color changes Cold intolerance Stiffness in the digits after exposure to cold Mild to severe pain that is relieved when the hand is warmed E. Patients may experience all the above symptoms. A. B. C. D.

B Fig. 1-33

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Kasdan, Amadio, Bowers, pp. 282-283 Hunter, Mackin, Callahan, p. 962

67. Ligaments about the elbow provide roughly what percent of joint stability? A. B. C. D.

25% 50% 75% 90%

Roughly half of elbow joint stability is provided by ligaments. Acute or recurrent instability can occur medially or posterolaterally. An acute tear of the medial collateral ligament is the most common isolated ligament injury of the elbow. Answer: B Varitimidis, pp. 66-71 Barnes, Tullos, pp. 62-67

Muscle 1. 2. 3. 4. 5.

Middle deltoid Upper trapezius Latissimus dorsi Coracobrachialis Pectoralis minor

Actions A. Protraction, depression, and downward rotation of

the scapula B. Flexion and adduction of the humerus C. Elevation and upward rotation of scapula D. Extension, internal rotation, and adduction of the

humerus E. Abduction of humerus to 90 degrees

Answers: 1, E; 2, C; 3, D; 4, B; 5, A Sieg, Adams, p. 30


Answer: E

68. Match the following muscles with their actions.

Patients with vascular disease, such as Raynaud’s phenomenon, may complain of fingertips turning white then bluish, and redness may be reported when blood flow returns to the digits. Many of these patients will complain of pain when the extremity is cold. The pain is relieved when the extremity is warmed, but stiffness in the digits may follow warming of the extremity.

27

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Chapter 2

Intrinsic Mechanism

1. Match the following numbers with the corresponding letters in Fig. 2-1. Sagittal band Dorsal hood Terminal tendon Lateral bands Interosseous muscle Lumbrical muscle Long extensor tendon

A

2 INTRINSIC MECHANISM

1. 2. 3. 4. 5. 6. 7.

B

C

Answers: 1, B; 2, D; 3, A; 4, C; 5, G; 6, E;

7, F Rosenthal in Mackin, Callahan, Skirven, et al, p. 526 Hunter, Schneider, Mackin, p. 549 D

2. You are treating a patient with an ulnar nerve injury at the level of the wrist. One of your goals is to strengthen the intrinsic musculature. Which exercise is best suited for this patient?

E F

A. Joint blocking B. Hyperextension of the metacarpophalangeal (MCP) joints against rubber band traction C. Pinching putty into a cone with the interphalangeal (IP) joints held in extension D. Grip strengthening by using a hand helper with mild resistance

The lumbricals contract when the MCP joints are in flexion and the IP joints are in extension. When pinching putty into a cone by flexing the MCP joints and maintaining IP joint extension (Fig. 2-2), you are able to strengthen the lumbricals, interossei, and thumb

G

Fig. 2-1

29

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30

CHAPTER 2 ■ Intrinsic Mechanism

adductors. The patient can also use a piece of thermoplastic material and push it into putty to facilitate the same muscles (Fig. 2-3). Grip strengthening would not be as effective because the IP joints flex during the exercise; therefore the patient is able to use the extrinsic flexors. Joint blocking is also incorrect because it is a nonresistive exercise for the extrinsic flexors and because hyperextension of the MCP joints facilitates the extrinsic extensors. Answer: C

3. A boutonnière deformity presents with which of the following? A. MCP joint extension with IP joint flexion B. Flexion of the proximal interphalangeal (PIP) joint with hyperextension of the distal interphalangeal (DIP) joint C. Hyperextension of the PIP joint with flexion of the DIP joint D. Hyperextension of the PIP joint with DIP joint flexion

Stanley, Tribuzi, pp. 193, 199

Refer to Figs. 2-2 and 2-3

A boutonnière deformity is caused by an injury to the complex extensor mechanism of the digit. The central tendon is ruptured or interrupted at the PIP joint (zone III) level, thus contributing to a loss of function of the triangular ligament. The rupture of the central slip causes proximal displacement of the extensor mechanism and a palmar subluxation of the lateral bands. The extensor force is therefore concentrated on the DIP joint, which results in hyperextension and loss of flexion at the DIP joint. The flexor digitorum superficialis is unopposed, which causes increased PIP joint flexion. As the lateral bands sublux further, the PIP joint is unable to achieve full extension actively or passively.

Intrinsic strengthening

Answer: B Rosenthal in Mackin, Callahan, Skirven, et al, p. 514 Hunter, Mackin, Callahan, p. 536 Blair, p. 610

Refer to Fig. 2-4

Fig. 2-2

Lateral band

Disruption of central slip

Oblique retinacular ligament

Fig. 2-4


1996, Mosby.

Intrinsic strengthening with a tool

Fig. 2-3

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Isolated DIP joint flexion Isolated PIP joint flexion PIP joint extension Composite digital extension

Active and passive flexion exercises of the DIP joint (Fig. 2-5) prevent oblique retinacular ligament (ORL) tightness, centralize the lateral bands, and advance the central slip. It is important to note that the most disabling element of the boutonnière deformity is the limitation of DIP joint flexion, not the lack of PIP joint motion. Patients often complain of a weak grip and an inability to grasp and manipulate small objects with the tip of the digit. Answer: A Blair, p. 614

5. You are treating a patient after a hand replantation from transmetacarpal amputation. What dysfunction often develops that can be prevented? A. B. C. D.

Intrinsic-plus posture Boutonnière deformity Intrinsic-minus posture Extensor retinaculum lengthening

Intrinsic tightness Extrinsic tightness Triangular ligament tightness ORL tightness Extensor tendon adherence

If DIP joint flexion is more limited when the PIP joint is passively extended than when it is flexed, a tightness of the ORL results. To treat this condition, the therapist should perform ORL stretches (passive DIP joint flexion with the PIP joint held in extension) or jointblocking exercises or apply a dynamic DIP joint flexion splint with a P2 block.

■ From Hunter JM, Mackin EJ, Callahan AD: Rehabilitation of the hand: surgery and therapy, ed 4, St Louis, 1995, Mosby.

Scheker, Hodges, pp. 473-480

6. You are treating a patient in the clinic 8 weeks after a middle phalanx fracture and observe when the PIP joint is passively flexed at 90 degrees, the DIP joint can achieve 50 degrees of flexion; however, when the PIP joint is placed at 0 degrees, the DIP can achieve only 25 degrees of flexion. This is caused by which of the following? A. B. C. D. E.

Fig. 2-5

Answer: C

Answer: D Aulicino in Mackin, Callahan, Skirven, et al, p. 133 Hunter, Mackin, Callahan, p. 65 Walters, pp. 116-123

CLINICAL GEM: P1 refers to the proximal phalanx; P2 refers to the middle phalanx; and P3 refers to the distal phalanx.


A. B. C. D.

Hands replanted after a transmetacarpal amputation often develop an intrinsic-minus posture (claw hand). This occurs when the intrinsic muscles are injured. The distal portion becomes ischemic and causes loss of muscle function and may scar the intrinsic tendons into their canals in a lengthened position. This causes an imbalance in which the MCP joint remains extended during flexion while the IP joints move into flexion. It can be treated by splinting the MCP joints in slight flexion to help shorten the injured intrinsic tendons and by providing an outrigger for active-assistive IP extension to mimic intrinsic function 3 to 6 days postoperatively. A static anticlaw orthosis is applied around 3 to 4 weeks postoperatively.

4. Which exercise is most important for a patient to perform when developing a boutonnière deformity?

31

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Range-of-motion assessment MCP PIP DIP

Active (degrees)

Passive (degrees)

0/70 0/85 0/55

0/75 0/90 0/60

(NOTE: Wrist is at neutral during active and passive measures.) When the fist is fully flexed in the available range of motion and the wrist is passively flexed to 25 degrees, tension is felt in the digits as they pull into extension and are unable to maintain their flexed position. What might cause this patient to experience this tension? A. B. C. D. E.

Flexor tightness distal to the wrist Flexor tightness proximal to the wrist Joint capsular tightness Extensor tightness distal to the wrist Extensor tightness proximal to the wrist

During ongoing assessments of patients, it is important to determine the origin of the limitation and treat it accordingly. Therefore one must observe the surrounding joints and their effect on range of motion. The following definitions describe various levels of tightness patients may have. EXTENSOR TIGHTNESS PROXIMAL TO THE WRIST: To test, passively hold the digits in composite flexion while passively flexing the wrist. If the digits are pulled into extension as the wrist is passively flexed, extrinsic tightness proximal to the wrist exists. Note the position of the wrist when the extensor tension is first detected to document stiffness. EXTENSOR TIGHTNESS DISTAL TO THE WRIST: To test, passively hold the PIP and DIP joints in flexion and passively flex the MCP joint. If the PIP and DIP joints are pulled into extension when the MCP joint is passively flexed, extensor tightness distal to the wrist exists. FLEXOR TIGHTNESS DISTAL TO THE WRIST: To test, passively hold the PIP and DIP joints in extension and passively extend the MCP joint. If the PIP and DIP joints are pulled into flexion as the MCP joint is passively extended, flexor tightness distal to the wrist exists. FLEXOR TIGHTNESS PROXIMAL TO THE WRIST: To test, passively maintain digits in full exten-

sion and passively extend the wrist. If flexor tension develops and the digits are pulled into flexion as the wrist is extended, extrinsic flexor tightness proximal to the wrist exists. Note the position of the wrist when the flexor tightness is first detected to document stiffness. JOINT CAPSULAR TIGHTNESS: To test, measure active range of motion and passive range of motion. If the measurements are the same regardless of the position of the proximal and distal joints, joint capsular tightness is present.

7. You are treating a patient who sustained a Colles fracture 4 months ago. The following is noted during the re-evaluation:

Answer: E Colditz in Mackin, Callahan, Skirven, et al, p. 1032 Hunter, Mackin, Callahan, p. 1148 Walters, pp. 116-123

8. Which intrinsic muscle is the strongest? A. B. C. D.

Opponens pollicis Flexor pollicis longus (FPL) Abductor pollicis brevis (APB) Adductor pollicis (AP)

The AP is the strongest of the thumb intrinsics and is stronger than the extrinsic FPL. The abductor pollicis brevis is small and is the weakest. The AP is not only used for pinching, it assists in thumb supination, provides thumb MCP stability, and assists in extending the thumb IP joint to 0 degrees of extension through the extensor mechanism. If the EPL is impaired or lost, weak IP joint extension is achieved via insertion of fibers of the AP into the lateral bands. Together with APB, IP joint extension of the thumb is achieved.

32

Answer: D Brand, pp. 287, 291-293

9. Terminal tendon tenotomy (for treating a boutonnière deformity) restores which of the following? A. B. C. D.

PIP joint flexion Complete PIP joint extension DIP joint flexion Partial DIP joint extension

A terminal tendon tenotomy is performed primarily to improve DIP joint flexion; secondarily, the PIP joint extensor deficit may show improvement. DIP joint extension is provided by the ORL through a static ten-

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10. Which of the following is not a possible cause of swan-neck deformity? A. Intrinsic tightness B. Loss of the superficialis tendon C. Increased force from the extensor digitorum communis D. Landsmeer’s ligament tightness

The postural collapse deformity called a swan-neck deformity has numerous causes. When the lateral bands displace dorsally, the imbalances of forces present as hyperextension of the PIP joint with flexion of the DIP joint. A swan-neck deformity can be caused by increased forces through the extrinsic extensor or intrinsic tendons, PIP joint instability, loss of the flexor digitorum superficialis tendon, stretching of the transverse retinacular ligament, a lax volar plate, or release of the distal extensor attachment. Answer D is incorrect because in a swan-neck deformity, the ORL (Landsmeer’s ligament) lengthens. Answer: D Aucilino in Mackin, Callahan, Skirven, et al, p. 133 Rosenthal in Mackin, Callahan, Skirven, et al, p. 526 Hunter, Mackin, Callahan, pp. 65, 549 Stanley, Tribuzi, pp. 405-407

Refer to Fig. 2-6

Answer: False Rosenthal in Mackin, Callahan, Skirven, et al, p. 526 Alter, Feldon, Terrono in Mackin, Callahan, Skirven, et al, p. 1551 Hunter, Mackin, Callahan, pp. 549, 1318

Refer to Fig. 2-6

12. Which splint is most appropriate for a swanneck deformity? A. B. C. D.

Silver ring to the PIP joint Stack splint Gutter splint to the PIP and DIP joints No splint will help.

A Siris Swan-Neck Silver Ring Splint or a thermoplastic figure-of-eight splint at the PIP joint reduces or eliminates PIP joint hyperextension and decreases the imbalance of the lateral bands. It is important to understand that swan-neck deformity splints do not permanently correct the imbalance; after they are removed, the deformity will reoccur. Answer: A Silver Ring Splint Company Catalog Malick, Kasch, p. 132

Refer to Fig. 2-7 Lateral bands

CLINICAL GEM: Siris Silver Ring Splints are durable, attractive, and functional. Patients may choose to have gems inserted into these rings; the rings also are available in gold.

Volar plate Fig. 2-6


Blair, pp. 610-614 Rosenthal in Mackin, Callahan, Skirven, et al, p. 526 Alter, Feldon, Terrono in Mackin, Callahan, Skirven, et al, p. 1551 Hunter, Mackin, Callahan, pp. 549, 1318

A swan-neck deformity presents with hyperextension of the PIP joint and flexion of the DIP joint. This deformity is caused by an imbalance of forces in the digit. This imbalance is summarized as follows: the transverse retinacular ligaments stretch, the triangular ligament fibers shorten, and the lateral bands sublux dorsally, causing attenuation of the PIP joint volar plate.

Answer: C

11. In a swan-neck deformity, the lateral bands sublux volarly. True or False?

odesis effect. Patients can begin active range of motion immediately after tenotomy. If after surgery extensor deficits at the DIP joint are greater than 10 to 15 degrees, some surgeons recommend splinting the PIP and DIP joints in full extension for 10 days. The DIP joint must be monitored closely for extensor lags and appropriate splinting adjustments made.

33

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34


bricals are innervated by the deep branch of the ulnar nerve.

A

Answer: A Hunter in Mackin, Callahan, Skirven, et al, p. 32 Aulicino in Mackin, Callahan, Skirven, et al, pp. 129-132 Hunter, Mackin, Callahan, pp. 65, 549 Green, Hotchkiss, Pederson, pp. 605, 606 Linscheid, p. 12

14. If a patient has intrinsic tightness, which of the following is true about the PIP joint? A. Flexes more when the MCP joint is in flexion B. Flexes more when the MCP joint is extended C. Flexes the same degree regardless of the position of the MCP joint D. Does not flex at all B

■ Courtesy of the Silver Ring Splint Company; Charlottesville,

13. Which of the following is not true about the lumbricals? A. Four of the muscles are innervated by the median nerve. B. They insert onto the extensor assembly. C. They link the extrinsic flexor and intrinsic extensor mechanisms. D. They are weaker than the interossei muscles.

There are four lumbrical muscles that originate from the profundus tendon in the palm and insert on the radial side of the finger onto the dorsal apparatus. The lumbricals and the interossei flex the MCP joints and extend the IP joints. Because of its origin on the profundus, the lumbrical maintains its unique ability to modify tension between the FDP and IP extensors in all positions of the finger. The interossei are much stronger than the lumbricals. Answer A is incorrect because the two radial lumbricals are innervated by the median nerve and the ulnar two lum-

Fig. 2-7 VA.

When testing for intrinsic tightness, the MCP joint is held in extension while the PIP joint is passively stretched in flexion (Fig. 2-8, A). Next, the MCP joint is placed in flexion while the PIP joint is again passively stretched in flexion (Fig. 2-8, B). If the PIP joint can be passively flexed to a greater extent when the MCP joint is flexed than when it is extended, intrinsic tightness exists. If the PIP joint flexes more when the MCP joint is extended, as in answer B, extrinsic extensor tightness exists. Answer: A Aulicino in Mackin, Callahan, Skirven, et al, p. 133 Colditz in Mackin, Callahan, Skirven, et al, p. 1032 Hunter, Mackin, Callahan, pp. 66, 1148

15. The mallet finger can progress to which type of deformity if untreated? A. B. C. D.

Hyperplasia Boutonnière Swan-neck Jersey finger

A swan-neck deformity can occur from a mallet lesion. The severity of the deformity is proportional to the stability of the palmar plate at the PIP joint. If the PIP joint palmar plate is lax, swan-neck deformity increases, and the FDP flexes the DIP joint, thus further contributing to the deformity. If the possibility of surgery is entertained, the finger can be rebalanced with tenotomy of the central tendon at the PIP joint. It also can be treated with reconstruction of the ORL by using a free tendon graft.

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35

avulsed. The DIP joint is splinted at 0 degrees of hyperextension (the PIP joint is free) for 6 to 8 weeks (Fig. 2-9). Immobilization for 8 weeks is indicated in injuries that are more than 3 weeks old. An additional 2 weeks is indicated in a patient who loses extension quickly when the splint is weaned at 6 weeks. Studies have shown excellent results with compliant patients. Answer: C Malick, Kasch, p. 62 Grothe, pp. 21-24

B

Fig. 2-9 ■ From Evans RB: Therapeutic management of extensor tendon injuries, Hand Clin 2:157, 1986.

17. Which of the following is not an accurate statement about the ORL?

Fig. 2-8

Answer: C Rosenthal in Mackin, Callahan, Skirven, et al, p. 521 Hunter, Mackin, Callahan, p. 544

Refer to Fig. 2-6

A. If there is greater flexion of the DIP joint when the PIP joint is flexed rather than when the PIP joint is extended, there is a tightness of the ORL. B. It originates from the volar proximal phalanx and inserts into the distal phalanx. C. Its primary role is to extend the distal phalanx. D. It is taut at 70 degrees of DIP joint flexion.

16. A mallet deformity with bone avulsion should be splinted for how long? A. B. C. D.

4 4 6 6

to to to to

6 6 8 8

weeks, weeks, weeks, weeks,

with with with with

the the the the

DIP DIP DIP DIP

joint joint joint joint

in in in in

full extension slight flexion full extension slight flexion

A mallet finger occurs when the extensor tendon is disrupted at the terminal tendon. The patient presents with an inability to actively extend the DIP joint. Conservative management is recommended for the patient if less than one third of the articulating surface is

Extension of the distal phalanx has been postulated as a combination of the lateral bands and tenodesis of the ORL. However, most authors agree that the primary extensor of the DIP joint is from the action of the conjoined lateral bands that insert into the distal phalanx as the terminal tendon. The ORL contributes little to DIP joint extension. The ORL is considered a retaining ligament that maintains tendon centralization on the dorsum of the finger. Therefore answer C is incorrect. The ORL originates from the volar aspect of the proximal phalanx and passes obliquely dorsally and joins the lateral bands as it inserts into the distal phalanx. If this ligament is tight, DIP flexion will be limited more with


A

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36


PIP extension than with PIP flexion. The ORL is taut at 70 degrees of DIP flexion. Answer: C Aulicino in Mackin, Callahan, Skirven, et al, p. 133 Rosenthal in Mackin Callahan, Skirven, et al, pp. 509-510 Hunter, Mackin, Callahan, p. 65 Harris, Rutledge, pp. 713-716

Refer to Fig. 2-10

ORL

Fig. 2-11

Fig. 2-10

■ Redrawn from Tubiana R: The hand, Philadelphia, 1981, WB

Saunders.

18. Your 29-year-old patient is demonstrating increased PIP joint flexion with the MCP joint in flexion and less PIP joint flexion with the MCP joint in extension. What exercise is best suited for this patient? A. Graded putty exercises to allow MCP, PIP, and DIP joint flexion B. Table top exercise, flexion of the MCP joint while maintaining IP joint extension C. Joint blocking exercises while maintaining MCP joint extension D. Terminal extension exercises with the palm on the table while applying pressure over the PIP joint

If PIP joint flexion is less when the MCP joint is extended than when it is flexed, it is considered a positive intrinsic tightness test. Holding the MCP joint in extension or hyperextension and passively flexing the IP joints can stretch the intrinsic muscles. Therefore joint-blocking exercises to the PIP and DIP joints with the MCP joints held in extension or hyperextension would be the best choice. This exercise needs to be repeated frequently throughout the day. A joint-blocking device or orthosis can be fabricated to assist patients with their program (Fig. 2-11). Fig. 2-12 shows the patient’s active fist before performing the MCP joint blocking exercises. Fig. 2-13 shows the patient’s fist immediately after 10 repetitions in the blocking splint; active motion is increased significantly.

Fig. 2-12

Answer: C Smith in Green, Hotchkiss, Pederson, pp. 607-608

Refer to Fig. 2-13

CLINICAL GEM: Stretching of the lumbrical muscles can only be achieved by positioning the MCP joint in hyperextension and actively flexing the IP joint. The splint can be used to block, or one can simply be aware of the MCP joint.

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Terminal tendon

37

Lateral bands

Central slip

Sagittal band

Fig. 2-13

Fig. 2-14

19. Which structure(s) maintains the central position of the extensor tendon over the MCP joint?

20. You are treating a patient 3 months after a FDP tendon graft to the ring finger. You notice that every time he attempts to make a fist the IP joints extend rather than flex. Why might this be happening?

Collateral ligaments Shroud fibers/sagittal bands Central slip Lumbricals

The shroud fibers/sagittal bands stabilize the extensor tendons over the MCP joint. They arise from the extrinsic extensors and insert into the volar plate of the MCP joint. When these structures become attenuated, the patient is unable to extend the MCP joint from the flexed position. However, the patient is able to hold the finger at zero when placed there as the tendon relocates over the MCP joint. Nonoperative management involves splinting the MCP joint at zero for 3 to 4 weeks while allowing PIP joint motion. If this does not work, surgical repair is indicated. Answer: B Green, pp. 1964-1965

Refer to Fig. 2-14

A. B. C. D.

Paradoxical extension Quadrigia The patient is not giving full effort The tendon graft has ruptured

Normally, flexion of the IP joints depends on contraction of the profundus and relaxation of the lumbricals. In contrast, paradoxical extension is an abnormal phenomenon that occurs when the patient attempts to contract the profundus but instead the lumbrical is pulled proximally, thus resulting in PIP and DIP joint extension rather than flexion. Tendon laxity after a tendon graft can cause this phenomenon because the profundus contraction may have a greater effect on the lumbrical than on the graft. Paradoxical extension may also occur if the lumbrical is fibrotic or contracted and the profundus force is transmitted to the lumbrical tendon rather than the distal phalanx during muscle contraction.

A. B. C. D.

Answer: A Green, p. 623


Extensor tendon

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CLINICAL GEM: The involved finger will assume an intrinsicplus position when paradoxical extension occurs. 21. How is digital extension achieved? A. Extrinsic tendons and sagittal bands extend the MCP joint; intrinsic musculature forming oblique fibers extend the PIP joint; and lateral bands conjoin to extend the DIP joint. B. Extrinsic tendons extend the MCP joint and the PIP joint; lateral bands and the ORL extend the DIP joint C. Sagittal bands extend the MCP joint; the central slip extends the PIP joint; and the ORL extends the DIP joint. D. Lumbricals extend the MCP joint; the extensor hood extends the PIP joint; the terminal tendon extends the DIP joint.

Terminal insertion

The extensor digitorum communis, extensor indicis proprius, and extensor digiti quinti tendons combined with the encircling series of fibers of the sagittal bands extend the MCP joint and proximal phalanx. The extensor mechanism then trifurcates into the central slip and lateral bands. This mechanism is held centered by the transverse retinacular ligament and is joined by the tendons of the interossei and lumbricals. The central slip and intrinsic musculature extend the PIP joint and middle phalanx. The lateral bands conjoin to form the terminal tendon that inserts into the distal phalanx to extend the DIP joint.

38

Answer: A Harris, Rutledge, pp. 713-716 Smith in Green, Hotchkiss, Pederson, pp. 604-606 Martin, Collins, pp. 236-237

Refer to Fig. 2-15

22. You wish to strengthen thumb adduction for your patient. Which Baltimore Therapeutic Equipment (BTE) tool would be the best choice?

Central slip

Saggital band Dorsal and volar interossei

Vincula Lumbrical

Flexor digitorum profundus Flexor digitorum superficialis

Fig. 2-15 ■ The extensor apparatus of a finger. Coordinated interactive motions between lateral forces (from interossei and lumbricals) and between central forces from the extrinsic extensor tendons allow diverse finger motion and position. (From Martin DS, Collins ED: Manual of acute hand injuries, St Louis, 1998, Mosby.)

Terminal insertion

Lakial hands Central slip

Intermetacarpal ligament Lumbrical

Dorsal and volar interossei

Ch02.qxd 7/28/04 6:31 PM Page 39


A. B. C. D.

39

181—rope pull 701—wrist flexion and extension CPM mode 202—key-shaped

Tool number 202 is key-shaped. BTE Company recommends using this attachment to simulate keys of all types for lateral pinch strengthening. Thumb adduction is strengthened in lateral pinch. The other attachments would not be appropriate choices to strengthen thumb adduction. Answer: D BTE user’s guide, p. 305

Fig. 2-16

24. A 36-year-old butcher has been referred to you after a laceration to his left index finger dorsally in zone III. His surgery included primary repair of the central slip and lateral bands with K-wire fixation 3 weeks ago. The doctor wants therapy to begin with an early motion protocol. His K-wire was removed earlier that day. How do you begin his treatment?

A prefabricated static splint, a serial cast, or a custommolded thermoplastic splint that provides uninterrupted PIP joint extension at 0 degrees is worn for 6 weeks to allow sufficient healing time for the central slip (Fig. 2-16). It is crucial that the splint place the PIP joint at 0 degrees, otherwise it may result in the tendon healing in an elongated position and result in a lag secondary to tendon gapping. DIP joint flexion is encouraged to stretch the ORL, realign the lateral bands, and restore muscular balance. The splint is to be worn continuously until extensor lag is no longer present. If an extensor lag develops after active motion has begun, the patient is to return to immobilization for another week. Some experienced therapists begin the patient on limited active motion at the PIP joint after 5 weeks.

A. Fabricate a thermoplastic splint that maintains the PIP joint in 0 degrees of extension and begin exercises outside of the splint to the PIP joint 3 times a day; allow as much motion as possible. B. Fabricate a thermoplastic splint that provides 0 degrees of extension for the PIP and DIP joints and begin gentle DIP joint flexion and extension exercises. C. Begin PIP and DIP joint flexion and extension exercises immediately to decrease adhesions and fabricate a digital extension splint for night use only. D. Fabricate a thermoplastic splint that maintains the PIP joint in 30 degrees of flexion and begin DIP and PIP joint flexion and extension exercises.

A. Immediate surgery to reconstruct the central slip B. Splinting the PIP joint in full extension while allowing flexion of the DIP joint C. Splinting the PIP and DIP joints in full extension while allowing MCP joint flexion D. A PIP joint spring extension splint

Answer: B Evans in Mackin, Callahan, Skirven, et al, p. 555 Hunter, Mackin, Callahan, p. 578 Stanley, Tribuzi, pp. 375-376 Doyle in Green, Hotchkiss, Pederson, p. 1973

When the central slip and lateral bands are repaired the PIP joint as well as the DIP joint need to be supported in extension for 4 to 6 weeks. However, immobilization for 6 weeks can result in limited digital motion. Mobilization schedules can vary for each patient. Splinting the PIP and DIP joints in full extension for up to 6 weeks and beginning early motion exercises outside of the splint as early as 3 weeks are recommended. DIP joint flexion and extension are begun so as to glide the lateral bands and gentle active flexion of the PIP joint is


23. What is the preferred method for treating a closed boutonnière deformity?

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40


initiated, to no more than 30 degrees, at 3 to 4 weeks. If no extensor lag develops at the PIP joint, motion can progress to 40 to 50 degrees and 60 to 80 degrees by the next week. The extension splint is to be worn between exercise sessions. The average thickness of the central slip just proximal to the PIP joint is only 0.5 mm; therefore, flexion exercises are to be performed with caution. Complications include elongation of the central slip because of aggressive exercises or adhesions limiting the central slip from gliding over the proximal phalanx, which will increase tension at the repair site and cause attenuation or a gap formation. Take care not to be overly aggressive. Advance according to tendon integrity.

Ulnar drift

A

Answer: B Evans in Mackin, Callahan, Skirven, et al, pp. 554-556 Doyle in Green, Hotchkiss, Pederson, pp. 1974-1975 Hunter, Mackin, Callahan, pp. 577-578

25. True or false: The ulnar intrinsics of a patient with rheumatoid arthritis become tighter than the radial intrinsics. Crossed intrinsic transfer

The ulnar intrinsics become contracted because of a variety of dynamic and anatomic factors that occur in the rheumatoid hand, which can result in ulnar drift (Fig. 217, A). Cross intrinsic transfers can be performed by resecting the ulnar intrinsics and rerouting them to the radial side of the proximal phalanx (Fig. 2-17, B). These transfers can be performed in a patient exhibiting early rheumatoid arthritis or in conjunction with MCP joint arthroplasty in an attempt to rebalance the hand.

B

Answer: True Green, pp. 617-618

26. What is the only muscle that arises from and inserts into tendon? A. B. C. D.

Abductor digiti minimi quinti Dorsal interosseous Volar interosseous Lumbricals Fig. 2-17

The lumbrical muscles are the only muscles that arise and insert into tendons. They arise from the FDP tendons and insert into the extensor expansion of the extensor digitorum communis. The lumbricals are known as the “workhorses” of the hand; however, a consensus about the actual role of the lumbricals has not been reached. Jacobsen and associates have shown that the lumbricals are designed for high excursion and velocity production. Backhouse and Catton have indicated that the primary action of the lumbricals is to

extend the IP joints and that they are weak flexors of the MCP joint. Brand and Hollister have indicated that the lumbricals ensure that the MCP joints flex ahead of the IP joints, thus allowing the hand to grasp a large object. The lumbricals have fascinated researchers for years and will require further research before their role is fully understood.

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41

Answer: D Schreuders, Stam, pp. 303-305 Brand, Hollister, p. 330

Refer to Fig. 2-18

Fig. 2-19

A. B. C. D.

PIP joint subluxation Boutonnière deformity Extensor hood inflammation Collateral ligament sprain

In closed injuries, the boutonnière deformity may not be present at the time of injury. The boutonnière deformity presents with PIP joint flexion secondary to disruption of the central slip and DIP joint hyperextension caused by volar migration of the lateral bands. The deformity may take up to 20 days to develop. Early recognition may be facilitated by holding the PIP joint in full extension and testing the amount of DIP joint passive flexion. If the lateral bands have migrated volarly, DIP joint flexion will decrease. Answer: B Evans in Mackin, Callahan, Skirven, et al, p. 554 Hunter, Mackin, Callahan, p. 577 Doyle in Green, Hotchkiss, Pederson, p. 1971

Refer to Fig. 2-19

A. B. C. D.

Flexor pollici brevis First dorsal interossei Opponens digiti minimi Abductor digiti minimi

In early signs of recovery after an injury to the ulnar nerve, the muscles will return in order of innervation. The first muscle to return is the abductor digiti minimi, then the two remaining hypothenar muscles, and next is the ulnar two lumbricals and the interossei. The last three muscles to return are the first dorsal interossei, the adductor pollicis, and the deep head of the flexor pollicis brevis. Contraction of the abductor digiti minimi muscle is best sought when the patient opposes the thumb to the little finger. Usually a flicker is seen before the prime-mover action is detected. As recovery proceeds, the small finger will become abducted. Answer: D Wynn Parry, p. 89 Stanley, Tribuzi, p. 330

29. The critical corner is formed from what structures? A. Volar plate, proper collateral ligament, and accessory collateral ligament B. Common extensor tendon, lumbrical and interossei tendon insertions C. Joint capsule, A2 pulley, volar plate D. Transverse retinacular ligament, lumbrical and interossei tendon insertions

The critical corner is formed by the volar plate, proper collateral ligament, and the accessory collateral liga-


27. A 34-year-old patient sent to you from the emergency room with a diagnosis of a sprained middle finger presents with a painful, tender, and swollen PIP joint. Active motion is decreased and the finger is held in a semiflexed position. During testing you observe a 30degree loss of active extension of the PIP joint when the wrist and MCP joints are held in full flexion. What may develop?

28. What muscle is the first to recover after a lesion to the wrist in a patient with ulnar nerve paralysis?

Fig. 2-18 ■ The four lumbrical muscles. (From Brand PW, Hollister A: Clinical mechanics of the hand, ed 2, St Louis, 1993, Mosby.)

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ment where they converge at the base of the middle phalanx to provide stability to the PIP joint. Answer: A Campbell, Wilson in Mackin, Callahan, Skirven, et al, p. 396 Hunter, Mackin, Callahan, p. 378

30. Which of the following statements about the PIP joint is not true? A. It is a hinged joint. B. The accessory collateral ligament folds during maximal joint flexion. C. The lateral bands displace dorsally during flexion. D. The volar plate is thick and prevents hyperextension.

Motion at the PIP joint occurs primarily in flexion and extension. The soft tissues and osseous structures allow this articulation to function as a hinged joint. The radial and ulnar collateral ligaments are supportive structures. The accessory collateral ligament is taut in extension and the proper collateral ligament is taut in flexion. The volar plate lies volar to the PIP joint and prevents hyperextension. Answer C is incorrect because when the PIP joint flexes, the lateral bands displace palmarly so that the moment arms of the lateral bands decrease

progressively. This assists in the mechanically linked movements of the PIP and DIP joints.

42

Answer: C Linscheid, pp. 7-8 Hunter, Mackin, Callahan, Schneider, Osterman, p. 378 Campbell, Wilson in Mackin, Callahan, Skirven, et al, pp. 396-397

31. To restore MCP flexion in a patient with intrinsic paralysis due to ulnar nerve palsy, which procedure might the surgeon select? A. B. C. D.

ECRL 4-tail (Brand’s intrinsic transfer) FDS 4-tail (modified Stiles, Bunnell transfer) FDS lasso (Zancolli’s lasso procedure) All are appropriate surgical procedures.

All three of the above-named tendon transfer techniques are used to help restore gripping, correct claw deformity, and increase hand function after intrinsic paralysis. THE FDS 4-TAIL (MODIFIED STILES, BUNNELL TRANSFER): The FDS tendon to the long finger is split longitudinally into four equal tails. Each slip is passed through the lumbrical canal of each finger and inserted into the radial lateral bands of the middle, ring, and small fingers and the ulnar lateral band of the index (Fig. 2-20).

FDS

A

B

Fig. 2-20

■ Transfer of a flexor digitorum superficialis (FDS) to control “claw finger” deformity. Half of the distal tendon of the donor superficialis tendon (long or ring) is tenodesed initially across the PIP joint to prevent hyperextension deformity of the PIP joint. The superficialis tendon is divided into two to four slips, which are passed volar to the deep transverse metacarpal ligament and through the lumbrical canals to the dorsal apparatus. The individual slips may be inserted into (A) the lateral band of the dorsal apparatus or (B) the A2 pulley of the flexor sheath. This transfer does not add power to finger flexion. (Copyright Elizabeth Roselius. From Green DP, Hotchkiss RN, Ped-

erson WC: Green’s Operative hand surgery, ed 4, New York, 1999, Churchill Livingstone.)

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Answer: D Ozkan, Ozer, Gulgonen, pp. 35-42 Toth, p. 244 Omer in Green, Hotchkiss, Pederson, pp. 1531-1533

32. Which of the following is not true about a claw hand deformity? A. The muscle imbalances and deformities are progressive. B. The patient will be unable to flex the MCP joints and extend the IP joints. C. The patient presents with an intrinsic-plus position. D. All are true.

In ulnar nerve injuries with intrinsic paralysis, there is loss of the hypothenar musculature, ulnar two lumbricals, interossei, and adductor pollicis muscles. The lumbricals and interossei supply balance to the flexor and extensor systems. Without these intrinsic muscles the patient will be unable to flex the MCP joints and extend the IP joints or fully flex or extend his or her digits. The digits will collapse when attempting extension, flexion, or when gripping or manipulating objects with any resistance. This imbalance usually becomes more exaggerated over time, and remodeling of the skin and joints will occur. The MCP joints will elongate and stretch into hyperextension, and the IP joints will stiffen into flexion. The extensor tendons eventually become attenuated. If the imbalance progresses into deformity, this will compromise tendon transfer surgery results. Answer C is incorrect because the claw deformity will present as the intrinsic-minus posture.

ECRL

Answer: C Bell-Krotoski in Mackin, Callahan, Skirven, et al, pp. 800-802 Hunter, Mackin, Callahan, pp. 730-732

33. Match each muscle to the correct description: Fig. 2-21 ■ Alternative transfer of the ECRL to control “claw finger” deformity. The ECRL is passed around the radial side of the forearm and extended by a free tendon graft in two to four slips that pass through the carpal tunnel and volar to the deep transverse metacarpal ligament, through the lumbrical canals, and into the lateral band of the dorsal apparatus. This transfer adds power to finger flexion. (Copyright Elizabeth Roselius. From Green DP, Hotchkiss RN, Pederson WC: Green’s Operative hand surgery, ed 4, New York, 1999, Churchill Livingstone.)

Muscle 1. 2. 3. 4.

Lumbricals Opponens pollicis brevis Volar interossei Adductor pollicis


THE FDS LASSO (ZANCOLLI’S LASSO PROCEDURE): The FDS tendon is divided at the level of the proximal phalanx of each finger. The proximal stump of each tendon is pulled back, looped around the A1 pulley, and sutured on itself at the level of the MCP joint. After surgery, the MCP joints are maintained at 60 to 70 degrees of flexion and the IP joints in full exten-

sion. The position of the wrist varies according to the type of transfer. This intrinsic-plus positioning is used to prevent recurrence of the deformity. Protective splinting may be continued for up to 12 weeks.

THE ECRL 4-TAIL (BRAND’S INTRINSIC TRANSFER): A free tendon graft (usually the plantaris tendon) is sutured to the distal end of the ECRL tendon and divided into four slips. With the aid of a tendon passer, the four slips are passes through the interosseous space volar to the deep transverse metacarpal ligament and are stitched to the radial lateral bands of the middle, ring, and small fingers and the ulnar lateral band of the index finger or to the radial aspect of the proximal phalanx (Fig. 2-21).

43

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5. 6. 7. 8. 9. 10.


Interosssei Abductor digiti minimi Abductor pollicis brevis Palmaris brevis Opponens digiti minimi First dorsal interossei

44

Answer: True Rosenthal in Mackin, Callahan, Skirven, et al, p. 509 Hunter, Mackin, Callahan, p. 530

35. True or false: The first dorsal interossei plays an important role during lateral pinch.

Description

D.

E. F.

G. H.

I. J.

Answers: 1, E; 2, G; 3, I; 4, C; 5, D; 6, A; 7, F; 8, J; 9, B; 10, H Stanley, Tribuzi, pp. 20-21 Hunter, Mackin, Callahan, p. 34 Chase in Mackin, Callahan, Skirven, et al, p. 71

34. True or False: A rupture of the transverse retinacular ligament results in development of a swan-neck deformity.

The transverse retinacular ligament encircles the PIP joint. This ligament restrains dorsal displacement of the lateral bands. If the transverse retinacular ligament is injured, the lateral bands bowstring dorsally and contribute to the development of a swan-neck deformity (see Fig. 2-6). In contrast, the triangular ligament holds the lateral bands dorsally, and loss of this ligament results in the development of a boutonnière (see Fig. 2-19).

The first dorsal interossei is usually considered an index finger abductor and MCP flexor. Many of its fibers have their origin on the first metacarpal shaft and therefore act on the first metacarpal serving as a weak thumb adductor. The very important role that the first dorsal interossei plays is stabilizing the first CMC joint during lateral pinch and power grip. Without the first dorsal interossei, the CMC joint would radially sublux when it is loaded in the position of lateral pinch.

B. C.

fifth MCP joint Rotates and draws fifth metacarpal anteriorly Adducts thumb to the palm, gives power for grasping, and inserts into the extensor mechanism to assist the IP joint of the thumb into 0 degrees of extension Inserts on the medial or lateral aspects of the proximal phalanx into the lateral band of the extensor mechanism Have a moving site of origin Originates from the fascia and transverse carpal ligament and inserts on the proximal phalanx and extensor mechanism of the thumb; helps to extend the IP joint to 0 degrees of extension Inserts all along the body of the first metacarpal and rotates the thumb medially Assists with thumb adduction and plays a significant role for writing and typing Adducts the thumb, index, ring, and small fingers Wrinkles the skin on the ulnar side of the palm

Answer: True Brand, pp. 294-296

36. Match each ligamentous structure to the correct description: Structure Deep transverse metacarpal ligament Proper collateral ligament Accessory collateral ligament Sagittal bands MCP collateral ligaments Triangular ligament Transverse retinacular ligament Transverse carpal ligament

A. B. C. D. E. F. G. H.

Description 1. 2. 3. 4. 5. 6. 7. 8.

Taut at 25 degrees of IP flexion Prevents dorsal bowstringing Prevents volar shifting of the lateral bands Provides the pulley mechanism for the flexor tendon sheath Stabilizes the MCP volar plates Contractures of this ligament prevent MCP flexion Prevents dorsal shifting of the lateral bands Works with the volar plate to stabilize the IP joint from lateral stresses

A. Increases span of grasp and assists with flexion of the

Answers: 1, B; 2, D; 3, F; 4, H; 5, A; 6, E; 7, G; 8, C Stanley, Tribuzi, pp. 7-8

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Answer: False Kader, pp. 185-186

38. True or false: A sprain to the PIP joint most frequently involves injury to the ulnar collateral ligament.

A sprain to the PIP joint is common in athletics and occupational settings. This common sprain usually injures the radial collateral ligament and the volar plate. In the usual injury, the collateral ligament ruptures proximally. This event is followed by tearing of the accessory collateral ligament and then rupture of the distal volar plate.

Answer: D Vicar, p. 10

40. You are treating a patient after volar dislocation of the PIP joint. What structure(s) might be damaged? A. B. C. D. E.

Lateral bands Superficialis tendon Central slip A and C are correct A, B, and C are correct

Volar or anterior dislocations of the PIP joint are less common than dorsal dislocations. Volar dislocations are often complex because they are irreducible closed and may involve extensive soft tissue damage. The mechanism of injury is usually a rotary force combined with compression. It usually occurs when an extended digit is forcibly flexed at the PIP joint. This lateral stress may rupture a collateral ligament, thus allowing the head of the proximal phalanx to buttonhole between the lateral band and the central slip. The central slip can then rupture or slip around the head of the proximal phalanx and be volar to it (Fig. 2-22). If the central slip remains

Answer: False Vicar, p. 6

39. A pseudoboutonnière deformity most commonly occurs in which finger? A. B. C. D.

Index Ring Middle Small

A pseudoboutonnière deformity is a flexion deformity of the PIP joint without DIP joint hyperextension. It results from a proximal avulsion of the volar plate that develops into a flexion contracture after the patient protectively holds the finger in a flexed position over time. The volar plate heals in a proximal position. This occurs most often in the small finger. If conservative treatment

Fig. 2-22 ■ Volar dislocation of the PIP joint is a relatively uncommon injury. It should be obvious from this radiograph that the central slip must be torn for this injury to occur; therefore these patients should be treated in the same manner as those with a boutonnière injury. (From DeLee JC, Drez D, Miller MD: DeLee & Drez’s Orthopaedic sports medicine, ed 2, Philadelphia, 2003, Saunders.)


The intrinsic musculature innervated distal to the level of the replantation will not be functional at this time as nerve regeneration will not have reached the intrinsic muscles at 4 weeks. An accepted concept is that nerve regeneration occurs roughly 1 mm/day or 1 inch/month in the hand. At 4 weeks, thumb and small finger opposition will not be possible. The patient will compensate by using the FPL for lateral pinch. Decreased active PIP and DIP extension will be observed because of the denervated lumbricals and interosseous muscles.

with PIP joint extension splinting is to no avail, the patient may require surgical intervention to release the proximal volar plate, excise the accessory collateral ligament, and free up the lateral bands. Extension can then be maintained with a K-wire, followed by assisted range of motion (AROM) and intermittent extension splinting.

37. True or false: Initiating active muscle contraction of the intrinsic musculature at 4 weeks is important for the treatment of a patient after a hand transplant.

45

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46


Vicar, p. 10 DeLee, Drez, Miller, pp. 1392-1393

41. Secondary defects of a hand with intrinsic paralysis include all but which of the following? A. B. C. D. E.

Flexion contractures of the PIP joints Extrinsic flexor tightness Anterior displacement of the lateral bands Attenuation of the extensor mechanism All are true.

Intrinsic paralysis can be caused from penetrating injuries, fractures, and entrapment syndromes. Most hands with paralysis of the ulnar innervated muscles will eventually develop clawing. When paralysis is progressive, the intrinsic-minus posture will be more evident. Without lumbrical or interossei activity the MCP joints are unable to flex and will hyperextend because of the unopposed pull from the EDC. The IP joints will be unable to extend; therefore the PIP joints will rest in a flexed position. Because of this positioning, the patient often develops PIP joint flexion contractures, adaptive shortening of the extrinsic finger flexors, adaptive growth of the extensor hood, and anterior displacement of the lateral bands. Answer: E Hunter, Mackin, Callahan, p. 732 Bell-Krotoski in Mackin, Callahan, Skirven, et al, pp. 802-803 Brandsma, pp. 14-17

42. How much strength do the intrinsic muscles contribute for power grasp? A. B. C. D.

30% 50% 40% 20%

The intrinsic muscles contribute half the strength of power grasp. In high ulnar nerve palsy grasp weakens by 60% to 80% secondarily to the additional loss of the ulnarly innervated fourth and fifth FDP. Answer: B Hastings, Davidson, p. 171

A. Unrepaired profundus tendon distal to the insertion of the superficialis tendon B. Heavy adhesions on the profundus tendon distal to the lumbrical insertion C. Gap formation of a repaired profundus tendon in zone V D. An FDP graft that is too long

Paradoxical extension (lumbrical plus) is a phenomenon in which the FDP glides too far proximally, thus transmitting its force to the extensor mechanism via the lumbricals. The lumbricals originate from the FDP and insert onto the radial side of the MCP joint and into the central slip and lateral bands. When the patient attempts to make a fist, the MCPs flex and the IPs extend because of the increased tension on the lumbricals. Paradoxical extension can be caused by an unrepaired FDP injury distal to the lumbrical origin, flexor tendon grafts of excessive length, adhesions of the lumbricals to a repaired FDP, or heavy FDP adhesions usually occurring in zone III. Answer C is incorrect because zone V is too proximal.

Answer: D

43. All but which of the following can cause paradoxical extension?

Answer: C Stanley, Tribuzi, p. 38

44. True or false: A patient with median nerve palsy can continue to achieve true opposition of the thumb to each of the fingertips by using the ulnar innervated half of the flexor pollicis brevis.

With median nerve palsy, the ulnar innervated one half of the FPB can substitute for palmar abduction and allow the patient to touch the thumb to each fingertip. However, this is with a lateral approach. The thumb makes contact with the lateral aspect of the digit. Without the opponens pollicis, the thumb is unable to rotate or pronate and cannot achieve true opposition (tip to tip).

dorsal to the head of the proximal phalanx, the lateral bands can lock under the condyle. The FDS is not injured with this injury.

Answer: False Stanley, Tribuzi, pp. 333-334

45. True or false: Surgical overcorrection of a paralytic claw hand will turn into an intrinsic-plus deformity.

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Overcorrection will reverse an intrinsic-minus deformity into an intrinsic-plus deformity. The hypermobile hand will develop PIP joint hyperextension with DIP joint flexion (also known as swan-neck deformity; see Fig. 2-23). Some of the causes include an overly strong muscle transferred to the extensor apparatus, a strong tendon transfer to the A1 pulley that limits MCP extension (the patient will attempt to straighten the finger and pull too hard with the long extensor tendons), and loss of the FDS can unbalance the PIP joint and cause hyperextension. Answer: True Brand, Hollister, pp. 203-204

ACL

PCL

47

CET

VP

Fig. 2-24

■ PIP joint. The major retaining ligaments of the PIP joint include the proper and accessory collateral ligaments (PCL and ACL), the volar plate (V P), and the dorsal capsule, with its central extensor tendon (CET ). The VP acts as a gliding surface for the flexor tendon. (From Mackin

Answer: D Campbell, Wilson in Mackin, Callahan, Skirven, et al, p. 396 Hunter, Mackin, Callahan, p. 378

Refer to Fig. 2-24

47. The diagnosis “saddle syndrome” refers to which of the following?

Fig. 2-23

46. Which of the following does not apply to the accessory collateral ligament at the PIP joint? A. B. C. D.

It It It It

is a stabilizer of the PIP joint. is taught in extension. inserts into the volar plate. is taut in flexion.

The proper collateral ligament (PCL) and accessory collateral ligament (ACL) are primary stabilizers of the PIP joint. The ACL is an anterior continuation of the joint capsule and attaches to the volar plate. In full extension, the ACL becomes taut; the PCL is taut in flexion. These ligamentous structures must be considered when splinting. Splinting the PIP joint at 0 to 15 degrees of flexion is recommended for treating collateral ligament injuries.

A. Inflammation of the thumb carpometacarpal joint B. Pain in the saddle-shaped joint surfaces of the upper extremity C. Inflammation of the sagittal bands D. Painful adhesions of the interosseous-lumbrical tendons

The interosseous and lumbrical tendons join distal to the deep transverse metacarpal ligament radial to the MCP joint of the long, ring, and small fingers. After closed injuries or repetitive microtrauma to the hand there can be painful adhesions to these structures. The painful condition in which the interosseouslumbrical adhesions are impinging on the deep transverse metacarpal ligament during intrinsic contraction is called saddle syndrome or saddle deformity (Fig. 2-25). The patient will experience pain with the Bunnell test (passive flexion of the IP joints while the MCP joints are supported in extension), while gripping, and during active intrinsic function.


EJ, Callahan AD, Skirven TM, et al: Hunter, Mackin, & Callahan’s Rehabilitation of the hand and upper extremity, ed 5, St Louis, 2002, Mosby.)

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48


Answer: D Rosenthal in Mackin, Callahan, Skirven, et al, pp. 511-512 Hunter, Mackin, Callahan, pp. 532-534 Tan, Rothenfluh, Beredjiklian, pp. 639-643

Ring finger

Adhesions dTML Lumbrical Palmar interosseous

Fig. 2-25

■ From Tan V, Rothenfluh DA, Beredjiklian PK, et al: Interosseous-lumbrical adhesions of the hand: contribution of magnetic resonance imaging to diagnosis and treatment planning, J Hand Surg [Am] 27(4):639-43, 2002.

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Chapter 3

Evaluation

1. Which of the following images represents a normal attitude of the hand?

Fig. 3-1, A, represents the normal attitude of the hand in the resting position. Notice the fingers are progressively more flexed as one moves from the radial to the ulnar digits. In Fig. 3-1, B, the fingers are contracted as a result of Dupuytren’s disease; therefore the normal attitude of the hand is lost. In Fig. 3-1, C, the normal attitude of the hand is lost because of lacerations of the flexor tendons in the fifth digit.

A

Fig. 3-1 ■ A, B, and C From Mackin EJ, Callahan AD, Skirven TM, et al: Rehabilitation of the hand and upper extremity, ed 5, vol 1, St Louis, 2002, Mosby.

Answer: A Aulicino in Mackin, Callahan, Skirven, et al, p. 122

B

C D. None of the above

A. B. C. D.

Jersey finger Mallet finger Oblique retinacular ligament (ORL) injury Crush injury to the distal interphalangeal (DIP) joint

The patient most likely has a mallet finger in which the digit presents with a “droop” of the tip of the finger at the DIP joint as a result of injury to the extensor tendon at the distal phalanx level. The treatment plan will be immobilization of the DIP joint in full extension for 6 to 8 weeks to allow the tendon to heal. 49

3 EVALUATION

2. You are treating a patient who injured his middle finger while playing basketball. He is unable to extend the tip of his finger. What is the most likely diagnosis?

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50

CHAPTER 3 ■ Evaluation

Answer: B Jebson, Kasdan, p. 15

3. A right hand–dominant patient is referred to you with a diagnosis of right wrist pain. Upon evaluation you note that the onset of symptoms was approximately 1 week ago, after the patient performed excessive digging with a shovel while installing a fence. The patient has tenderness over the flexor carpi radialis (FCR) insertion and reports severe pain with passive extension. The patient has no signs of atrophy, crepitus, or loss of sensation. You consider possible FCR tendonitis. All but which of the following represent symptoms of acute tenopathy? Localized pain Pain with stretch to the tendon Pain with resisted tendon function Localized swelling Crepitus

Acute tendonitis typically can present with all of the above except crepitus, which is a sign for more chronic cumulative trauma. Crepitus occurs as the tendon glides through adhesions and thickened tissues between the tendon and synovium that have developed over time. It is important to identify the stage of injury to provide appropriate treatment for the patient. For example, in this patient’s case, splinting is indicated to rest the tendon and allow for inflammation to subside. In a more chronic case of tendonitis, tendon gliding may be a primary goal in treatment.

Scaphoid nonunion Basal joint arthritis Scapholunate (SL) injury Intersection syndrome All of the above

The other diagnosis that could be indicated is intersection syndrome. Intersection syndrome occurs at the friction point where the muscles of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) cross over the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB). The patient with intersection syndrome will experience superficial tenderness on the dorsal radial wrist approximately 4 to 5 cm proximal to the radial styloid. They will also have pain with resisted thumb metacarpophalangeal (MCP) extension and will often have a positive Finkelstein’s test. You can rule out scaphoid nonunion, basal joint osteoarthritis (BJOA), and SL injury from the negative tests described in the question.

A. B. C. D. E.

A. B. C. D. E.

Answer: D Lee, Nasser-Sharif, Zelouf in Mackin, Callahan, Skirven, et al, p. 945 Skirven, Osterman in Mackin, Callahan, Skirven, et al, p. 1103

Refer to Fig. 3-2

Extensor carpi radialis brevis

Compartment 2

Answer: E Lee, Nasser-Sharif, Zelouf in Mackin, Callahan, Skirven, et al, pp. 931-932, 943

4. A patient is referred for conservative treatment of posttraumatic DeQuervain’s tenosynovitis 6 months after a motor vehicle accident (MVA). During the evaluation, you note tenderness 4 to 5 cm proximal to the radial styloid as well as at the anatomical snuffbox. The patient has a positive Finkelstein’s test, negative hitchhiker’s test, negative Watson’s test, negative Grind test, pain with resisted wrist extension, no significant superficial tenderness on the dorsal aspect of the wrist, and no radiographic evidence of fracture. What other diagnosis may be indicated in addition to or instead of DeQuervain’s?

Extensor carpi radialis longus

Extensor pollicis brevis Compartment 1 Abductor pollicis longus

Fig. 3-2

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51

5. A patient who is employed as a data entry technician is referred to you with a diagnosis of lateral epicondylitis. The patient has received two cortisone injections without relief and is now sent for conservative treatment. The patient describes pain throughout the lateral arm but reports the most pain in the mobile wad of Henry. Some tenderness is noted at the lateral epicondyle. Patient has pain with resisted supination and resisted middle finger extension. Which of the following is a likely differential diagnosis?

Hornbach, Culp in Mackin, Callahan, Skirven, et al, pp. 691-692 DeLee, Drez, Miller, p. 1328 Szabo in Green, Hotchkiss, Pederson, pp. 1433-1437

CLINICAL GEM: Interestingly, some patients present with weakness in the extensors with a radial tunnel syndrome. This “pseudo” weakness occurs because the patient’s protection from pain and is not a “true” muscle weakness.

Radial tunnel Dorsal wrist syndrome Radiocapitellar joint pathology ECRL tendonosis

The differential diagnosis is radial tunnel. Differentiation between the two syndromes is difficult because of the overlapping symptoms and difficulty with physical examination. Radial tunnel and lateral eipicondylitis can coexist. Radial tunnel syndrome typically presents with pain without palsy in the dorsal forearm, localized at the ECRL/ECRB/brachioradialis muscle bellies (mobile wad of Henry). Pain is worst approximately 4 to 5 cm distal to the lateral epicondyle. Patients will typically complain of deep, burning pain that is exacerbated with activities requiring forearm pronation and wrist flexion. Patients may also report resting and night pain. Resisted extension of the middle finger with the elbow extended, wrist in neutral, and the forearm pronated will elicit pain in the radial nerve distribution and the edge of the ECRB. Also, testing resisted supination with the forearm extended will elicit pain in those patients with radial nerve compression at the arcade of Frohse. The latter two tests are typically negative in patients with tennis elbow. The following were incorrect choices. The radiocapitellar joint is not involved because of the patient’s report of pain distal to the lateral epicondyle. If the ECRL were involved, the insertion of this muscle would cause the patient to complain of pain proximal to this point. Finally, the patient with dorsal wrist syndrome will have pain elicited in the SL region and resisted finger extension while the wrist is flexed (Fig. 3-3).

Answer: A

CLINICAL GEM: Radial tunnel can occur with racquet sport injuries and manual labor workers.

1

3 4

2

3 EVALUATION

A. B. C. D.


Fig. 3-3

■ Four potentially compressive anatomic elements of the radial nerve: (1) fibrous bands overlying radial head and capsule; (2) fibrous origin of the ECRB; (3) radial recurrent arterial fan; and (4) arcade of Frohse. The distal margin of the supinator muscle has been considered a fifth site of compression. (From Moss S, Switzer H: Radial tunnel syndrome:

a spectrum of clinical presentations, J Hand Surg 8:415, 1983.)

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6. A patient is referred to therapy 6 weeks statuspost intraarticular fracture of the small finger proximal interphalangeal (PIP) joint. The patient was not splinted after injury, and at the time of evaluation, the finger assumed a PIP joint flexion posture. When the patient passively flexes the DIP joint with the PIP joint in extension and then repeats with the PIP joint in flexion, you discover that greater motion exists when the PIP joint is flexed then when it is extended. What is indicated as the cause for decreased DIP joint motion? A. B. C. D.

ORL tightness Joint contracture at the DIP joint Triangular ligament tightness All of the above could be indicated.

The ORL in this case has shortened secondarily to the flexed posture of the PIP joint. The ORL originates at the A2/C1 pulley area on the volar aspect of the proximal phalanx and inserts on the dorsal surface near the DIP joint. To test for ORL tightness, hold the PIP joint in extension and passively flex the DIP joint (Fig. 3-4, A). If flexion is less in this position than that measured with the PIP joint in flexion (Fig. 3-4, B), then ORL tightness is present. Joint contracture and/or triangular ligament tightness would present with limited passive DIP joint flexion regardless of the position of the PIP joint.

52

Answer: A Aulicino in Mackin, Callahan, Skirven, et al, p. 133

Refer to Fig. 3-4

7. A patient is referred after open reduction internal fixation (ORIF) of the distal radius and ulnar styloid after sliding into home plate at a softball game. Evaluation demonstrates limited digit active range of motion (AROM) is as follows 6 months after his injury: Index finger Middle finger Ring finger Small finger

MCP

PIP

DIP

WNL WNL +35/88 +40/90

WNL WNL -25/98 -30/100

WNL WNL -15/72 -15/72

NOTE: Positive (+) indicates hypertension. WNL, Within normal limits.

True or false: These numbers indicate a high ulnar nerve lesion is present.

Clawing of the ring and small fingers will be more dramatic in a low ulnar nerve palsy secondary to intact flexor digitorum profundus (FDP) innervation and unopposed FDP function of the ulnar innervated intrinsics. In a high ulnar nerve lesion, clawing is less noticeable secondary to the noninnervated FDP, which limits the clawing appearance at the interphalangeal (IP) joint level.

A

B


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Answer: False

8. Reflex testing is used to evaluate the integrity of nerve supply. The triceps reflex commonly is assessed for radial nerve function. This reflex is largely a function of what neurological level? A. B. C. D.

C5 C6 C7 C8

The radial nerve innervates the triceps. This reflex is largely a function of the C7 neurological level. To assess the triceps, place the patient’s arm over your opposite arm so that it rests on your forearm. Hold the patient’s arm under the medial epicondyle. Have the patient put his or her arm in a slightly flexed position, with the arm relaxed. With the narrow end of a reflex hammer, tap the triceps tendon where it crosses the olecranon fossa. You should be able to see the reflex or feel it slightly as the patient’s arm jerks your supporting arm. Answer: C

53

CLINICAL GEM: A reflex is an involuntary response to a stimulus. Reflexes depend on intact neural pathways.

Skirven, Callahan in Mackin, Callahan, Skirven, et al, p. 605

9. For optimal results during discriminative sensory reeducation, certain requirements must be met. A specific level of return in touch perception must be present for successful sensory retraining. With regards to SemmesWeinstein monofilaments, the patient must be able to perceive which level of sensory return in order to begin discrimination testing? A. B. C. D.

6.65 5.07 4.56 4.31

monofilament monofilament monofilament monofilament

A patient must have protective sensation (4.31) on the fingertips with monofilament testing before discrimination retraining can be initiated. If discriminative sensory reeducation is begun before this sensibility is obtained, the treatment will not be beneficial, and the patient may become discouraged.

Hoppenfeld, p. 55

Refer to Fig. 3-5


Answer: D Hunter, Mackin, Callahan, p. 706 Fess in Mackin, Callahan, Skirven, et al, p. 637

A. B. C. D. E.

Fig. 3-5

CLINICAL GEM: To assess C5, perform a biceps reflex test. To assess C6, perform a brachioradialis reflex test.

Poor minus Poor Poor plus Fair minus Fair

MMT involves observing, palpating, and manually resisting muscles or groups of muscles to determine the quality and quantity of muscle contraction. Contraindications to MMT include spasticity and situations in which AROM or resistance is not allowed, such as during the healing of bone, muscle, and tendon. Several grading scales have been noted in the literature and are used in academic programs. The following are the classifications and definitions from Trombly and Scott’s grading system.

3 EVALUATION

10. You are manual muscle testing (MMT) the triceps muscle and note that the patient can achieve full AROM only in the gravityeliminated plane (no added resistance). The triceps should be rated:

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54

Number

Definition

Zero (0)

0

Trace (T)

1

Poor-(P-)

2-

Poor (P)

2

Poor + (P+)

2+

No contraction palpable; no movement at joint Contraction/tension palpated in the muscle or tendon; no movement at joint Part moves through only a portion of range of motion on a gravityeliminated plane Part moves through full range of motion on a gravity-eliminated plane with no added resistance Part moves through full range of motion on a gravity-eliminated plane; takes minimal resistance and then “breaks” Part moves through less than full range of motion against gravity Part moves through full range of motion against gravity with no added resistance Part moves through full range of motion against gravity with minimal resistance Part moves through full range of motion against gravity with less than moderate resistance Part moves through full range of motion against gravity with moderate resistance Part moves through full range of motion against gravity with maximum resistance

Fair-(F-)

3-

Fair (F)

3

Fair + (F+)

3+

Good-(G-)

4-

4

Normal (N)

5

Good (G)

Green, p. 2254 Hunter, Mackin, Callahan, p. 74 Aulicino in Mackin, Callahan, Skirven, et al, p. 141

12. For a quick check of ulnar nerve status, which muscle would you test? A. B. C. D.

Abductor pollicis brevis Extensor indicis proprius Dorsal interossei Palmaris longus

Assessment of the dorsal interossei, which abduct the digits, is a quick test for ulnar nerve function. The extensor indicis proprius is innervated by the radial nerve; the abductor pollicis brevis and palmaris longus are innervated by the median nerve. Answer: C Hoppenfeld, p. 95

Answer: B Casanova, pp. 47-52 Trombly, Scott, p. 174

CLINICAL GEM: To remember the actions of the interossei, remember PAD and DAB. PAD refers to Palmar interossei ADduct, and DAB refers to Dorsal interossei ABduct.

11. Which is the most useful and widely known noninvasive test for evaluating the contribution of the radial and ulnar arteries to the hand? A. B. C. D.

Answer: A

CLINICAL GEM: A modification of Allen’s test can be performed on a single digit. The steps are the same as described in the question except that the examiner occludes and releases the radial and ulnar digital arteries.

Word


Allen’s test Plethysmography Arteriography Radionuclide studies

The Allen’s test is used to assess both ulnar and radial arteries of the hand. The examiner performs this test by compressing the arteries at the patient’s wrist (Fig. 3-6, A) and asking the patient to make a fist several times to exsanguinate the blood (Fig. 3-6, B). Next, the patient is asked to open the hand approximately 90% while one artery is released and the refill time is noted (Fig. 3-6, C ); the patient should not open the hand forcefully. The test is performed again with the other artery. The test is positive if there is no arterial flush in 5 to 15 seconds. This is a modification of the test originally described by Allen (see Fig. 1-31).

13. When one measures the radial and ulnar deviation of the wrist, the axis of the goniometer should be placed at which of the following? A. B. C. D. E.

Scaphoid Lunate Triquetrum Capitate Distal radius

During measurement of wrist deviation, the goniometer is positioned so that the stationary arm is aligned with the forearm, the axis is at the capitate, and the moveable arm is placed along the third metacarpal. Wrist flexion and extension should be avoided during the assessment. Normal range of motion is as follows: radial deviation, 0 to 20 degrees; ulnar deviation, 0 to 30 degrees.

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When assessing range of motion, the therapist should indicate whether active, passive, or torque range of motion is being measured. Joints typically are measured on the dorsal aspect, with the axis of the goniometer lining up with the axis of the joint. Recording any deviations in the method of assessing range of motion is imperative to allow for accurate future comparisons.

A

55

Answer: D Clinical Assessment Recommendations, p. 57 Hunter, Mackin, Callahan, pp. 102-103 Cambridge in Mackin, Callahan, Skirven, et al, pp. 176-178

CLINICAL GEM: A quick way to find the capitate is to slide your finger down the patient’s middle finger until you feel a divot in the wrist. The waist of the capitate lies beneath your finger. 14. A grind test on the thumb is performed to assess which of the following? B

A. B. C. D.

Osteoarthritis Tenosynovitis Rheumatoid arthritis Ligament weakness

The grind test is performed by applying mild axial compression and gentle rotation of the thumb. If osteoarthritis is present, this test will cause pain at the first carpometacarpal joint. Answer: A Hunter, Mackin, Callahan, p. 72 Aulicino in Mackin, Callahan, Skirven, et al, p. 138

Refer to Fig. 3-7

3 EVALUATION

C

Fig. 3-6 ■ Redrawn from American Society for Surgery of the Hand: The hand, examination and diagnosis, Aurora, CO, 1978, The Society.


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56


15. A patient developed a chronic stiff hand after immobilization of a distal radius fracture and has attended therapy for 6 weeks. Therapy has included joint mobilization, static progressive splinting, and active/active-assisted/passive range of motion (A/AA/PROM). Reevaluation shows that PROM of the digits is 90% of the contralateral hand; however, power grip remains limited because of decreased active DIP joint flexion. The patient has limited active clawing but full passive IP joint flexion in the hook (claw) position. This patient has most likely developed which of the following? A. B. C. D. E.

Interossei tightness Lumbrical tightness Limited FDP glide Both B and C All of the above

Lumbrical tightness is present, and because of the FDP origin of the lumbricals on the FDP, limited FDP glide also occurs and affects the functional power grip of the hand. The interossei are not tight; this fact is evidenced by full passive IP joint flexion in the claw position. Answer: D

CLINICAL GEM: The casting motion to mobilize stiffness (CMMS) technique described by Judy Colditz will be useful to position the DIP joints in greater flexion and to aid in pull-through of the profundus tendons when treating patients with decreased active DIP joint flexion due to chronic stiffness (Fig. 3-8).

16. A patient is seen s/p Smith’s fracture and has been progressing well in treatment. Functional range of motion (ROM) is achieved; however, the patient continues to complain of ulnarsided wrist pain that is exacerbated with supination. The patient also experiences pain with power grip combined with supination; however, the patient’s grip is pain-free when combined with pronation. Which of the following is the most likely joint dysfunction that is contributing to pain and functional loss? A. B. C. D.

Triangular fibrocartilage complex (TFCC) injury Ulnar abutment Distal radioulnar (DRU) joint volar instability Posttraumatic arthritis

Colditz in Mackin, Callahan, Skirven, et al, p. 1044

Refer to Fig. 3-8

Volar instability at the DRU joint is likely the cause of joint dysfunction in this case. One can draw this conclusion from the mechanism of injury (volar dislocation) seen in Smith’s fractures. This patient presents with pain in supination when power gripping, which is a more unusual presentation than is often seen with a typical Colles fracture and resultant TFCC injury. However, with a TFCC injury or in ulnar abutment, the ulnar structures are relatively unloaded with supination, and pain would be predominantly associated with pronated power grip. If the patient had posttraumatic arthritis the pain will occur with both supination and pronation.


Answer: C Frykman, Watkins in Mackin, Callahan, Skirven, et al, p. 1132 LaStayo in Mackin, Callahan, Skirven, et al, p. 1157

17. Match the following test to the correct description:

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Test 1. 2. 3. 4. 5.

Jebsen hand function test Crawford small parts dexterity test Rosenbusch test of finger dexterity Purdue pegboard Minnesota rate-of-manipulation test

Description A. Fine-motor coordination test that uses tweezers and

screwdrivers coordination test that addresses bilateral turning and placing C. Test that focuses on the ability to simultaneously hold, manipulate, and place small objects D. Test that involves the manipulation of washers, small pins, and collars E. Test that is used to assess activities-of-daily-living skills

B. Gross-motor

A. B. C. D. E.

Handle Handle Handle Handle Handle

position position position position position

57

I II III IV V

The Jamar dynamometer (Fig. 3-9) is a standardized instrument used for grip testing. It has five adjustable settings. The American Society of Hand Therapists (ASHT) recommends that the patient be seated comfortably during testing, with the shoulder adducted, the elbow flexed to 90 degrees, and the forearm and wrist in neutral positions. There is controversy regarding the optimal wrist position. Most authors report that the wrist should be positioned between 0 and 30 degrees. Extension that exceeds 30 degrees should be noted. Both the American Society of Surgery of the Hand (ASSH) and ASHT recommend testing in the secondhandle position (if only one handle span is used) as well as obtaining three grip trials.

Answers: 1, E; 2, A; 3, C; 4, D; 5, B Hunter, Mackin, Callahan, p. 211 Fess in Mackin, Callahan, Skirven, et al, pp. 278-279

18. To what does a coefficient of variation (COV) of 20% refer? A. B. C. D.

A good level of effort Consistent effort Inconsistent effort Malingering

3 EVALUATION

A COV provides a percentage of variation between trials of a test. This information can be used to assess a patient’s level of effort during testing. Factors that may interfere with a patient’s performance include anxiety, fear of pain or reinjury, difficulty understanding the testing procedures, and other impairments. According to an accepted standard, a COV of 15% or less means that the patient’s performance is at a good level of effort; a COV of greater than 15% is considered inconsistent. The authors believe that COV results should be interpreted with caution. Answer: C Hunter, Mackin, Callahan, pp. 1739-1774 Schultz-Johnson in Mackin, Callahan, Skirven, et al, pp. 1981-2025

19. Which handle position on the Jamar dynamometer is widely accepted for testing?

Fig. 3-9 ■ From Pedretti LW: Occupational therapy: practice skills for physical dysfunction, ed 4, St Louis, 1996, Mosby.

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Answer: B Clinical Assessment Recommendations, pp. 41-44 Aulicino in Mackin, Callahan, Skirven, et al, p. 134

CLINICAL GEM: Research has indicated that a 5% to 10% difference between the normal dominant hand and the normal nondominant hand usually exists.

20. A 5-year-old girl is referred to you for evaluation of her sensibility 3 months after a median nerve repair. Which test would best determine her status of sensibility? A. B. C. D.

Two-point discrimination (2PD) Semmes-Weinstein monofilament testing Moberg pick-up test O’Connor tweezer dexterity test

The Moberg pick-up test is the best choice for testing a child’s functional level of sensibility because a child may find other sensory tests may be confusing and therefore could easily misunderstand them. The Moberg test is a nonstandardized test that consists of picking up everyday objects and placing them in a container. One may choose to use this as a clinical tool for sensory and motor reeducation; however, if the Moberg test is used in this manner, it should not be used for testing. Answer: C Dellon, pp. 86-104

CLINICAL GEM: When addressing tactile gnosis after a median nerve injury, the therapist should decrease sensory input to the ulnar nerve–innervated digits to ensure that object recognition is being determined by the median nerve–innervated digits. One way to ensure this is to modify a glove by cutting away the median-innervated digits (index, thumb, and long) and keeping ring and little finger glove material intact.

21. Match each Semmes-Weinstein monofilament classification with the correct filament thickness.

Classification 1. 2. 3. 4. 5.

Normal Diminished light touch Diminished protective sensation Loss of protective sensation Not testable

Filament Thickness A. B. C. D. E.

3.22 Greater than 6.65 5.46 2.44 4.08 Color key to correlate with monofilament results

Green Blue Purple Red Red-lined

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Normal sensation Diminished light touch Diminished protective sensation Loss of protective sensation Not testable

1.65-2.83 3.22-3.61 3.84-4.31 4.56-6.65 Greater than 6.65

Answers: 1, D; 2, A; 3, E; 4, C; 5, B Hunter, Mackin, Callahan, pp. 120-121 Bell-Krotoski in Mackin, Callahan, Skirven, et al, pp. 199, 204

CLINICAL GEM: When assessing with the Semmes-Weinstein monofilament (SWM) classification, remember to bowstring the monofilament at a perpendicular angle to the finger. Monofilaments 1.65 through 4.08 are applied three times per targeted area. One out of three quantifies as a correct response; larger monofilaments are applied only one time to each targeted area.

CLINICAL GEM: Each monofilament thickness has a range of numbers that correlates with a specific color. When the Semmes-Weinstein monofilament results are completed, a hand diagram is colorcoded. Color coding provides a quick reference to the person’s level of sensibility. Repeat mappings should be performed to determine sensory recovery.

22. Your patient is being referred for an arthrogram to confirm which of the following suspected diagnosis?

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A. B. C. D.

TFCC tear Scaphoid fracture Dorsal wrist ganglion All of the above are good candidates for arthrograms.

A. B. C. D.

Answer: A Jebsen, Kasdan, p. 39

Lumbrical weakness Central slip rupture Lateral band subluxation Central slip adhesion

The patient incurred a central slip rupture when the finger was struck. The central slip provides initiation of extension of the PIP joint as well as the final 15 to 20 degrees of extension. The patient’s ability to hold extension when the PIP joint is placed in extension is performed by the lateral bands. The patient is unable to initiate PIP joint extension because of loss of the central slip.

Wrist arthrography is often indicated to confirm suspected tears of the TFCC as well as other ligament tears, such as the SL or lunotriquetal ligaments. This technique is useful to detect leakage of fluids into joint spaces and diagnose tears of these ligaments. The ganglion could be confirmed by using an ultrasound imaging technique to confirm its existence, and the scaphoid fracture could be confirmed with X-ray or magnetic resonance imaging (MRI).

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23. A patient is seen 2 years after a crush injury to the middle finger (MF). The patient reports hitting the dorsal PIP joint approximately 6 months ago and feeling a “snap.” The PIP joint rests in 60 degrees of flexion but is passively correctable. The patient is unable to initiate PIP joint extension with the joint in flexion. You also discover that with the MCP joint at neutral and the PIP joint placed in extension the patient can hold the digit in relative extension. Additionally, while placing the wrist and MCP joints in flexion and assessing active PIP joint extension the patient has a 15- to 20degree lag at the PIP joint. The likely diagnosis is which of the following?

Answer: B Rosenthal in Mackin, Callahan, Skirven, et al, pp. 513-514

Refer to Fig. 3-10

24. A 36-year-old man presents with “balloon” edema in the right, dominant hand. You choose to test the edema using a volumeter. When this test is performed, the patient should lower his hand until the stop dowel rests at which web space? A. B. C. D.

Web Web Web Web

one two three four

T

A

B C U

Fig. 3-10 ■ Closed rupture of extensor tendon about the PIP joint. Active and passive extension were limited. There was no resistance to flexion of distal joint. A, Clinical posture of injured finger. B, Operative findings: central tendon ruptured with herniation of head and proximal phalanx; triangular ligament was preserved. Radial lateral band is trapped beneath the condyle of the proximal phalanx. Inability to passively extend the PIP joint is indication for primary operative repair in extensor tendon injuries at this level. C, Central tendon; R, radial lateral band; T, triangular ligament; U, ulnar lateral band. (From Mackin EJ, Callahan AD, Skirven TM, et al: Rehabilitation of the hand and upper extremity, ed 5, vol 1, St Louis, 2002, Mosby.)

3 EVALUATION

R

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Answer: C Hunter, Mackin, Callahan, p. 81 Villeco, Mackin, Hunter in Mackin, Callahan, Skirven, et al, p. 188

26. True or false: A safety pin is a good tool for assessing pain perception.

A sharp/dull test is used to assess pain perception. According to Waylett-Rendall, a sterile needle should be used instead of a safety pin because denervated skin lacks calluses for protection and is more susceptible to damage. The test is performed to slight blanching to prevent puncture. According to Moberg, Dellon, and others, pinprick (sterile needle) is not recommended because of discomfort and poor correlation with functional sensation. However, if sensibility return is absent, it may be used to determine when protective sensation is intact.

In a hand volumeter test, water is poured into the volumeter until overflow occurs and the overflow is discarded. Remove all jewelry from both upper extremities of the patient. Next, while the patient is standing, ask him to lower his hand slowly into the volumeter with his thumb facing the spout and forearm in pronation (palm facing the patient), until the third web rests on the stop dowel (the third web is between digits three and four) (Fig. 3-11). The patient’s hand is removed, and water is measured in the graduated cylinder.

Answer: False Clinical Assessment Recommendations, p. 73 Hunter, Mackin, Callahan, p. 144

27. Match each of the following tests with the correct description/names. Tests


1. 2. 3. 4. 5.

Ninhydrin test Semmes-Weinstein Moving two-point Static two-point Moberg pick-up test

Description/Names

25. True or false: A neural tension test is positive if a patient feels any tingling or discomfort during the test.

A neural tension test, according to Butler, is positive when it reproduces the patient’s symptoms or current complaints. One must realize that in “normal” people tension testing may cause some discomfort or numbness. Clinicians should familiarize themselves with the expected responses. Answer: False Butler, p. 162

A. B. C. D. E.

CLINICAL GEM: When only one or two digits are involved, circumferential measurement is more useful because the edema in an individual joint or digit may not be detected with the volumeter.

Weber Dellon Threshold testing Sudomotor function Functional test for tactile gnosis

Answers: 1, D; 2, C; 3, B; 4, A; 5, E Clinical Assessment Recommendations, pp. 71-77

28. Which of the curves in Fig. 3-12 represents a treatable torque angle curve for a 50-degree PIP joint contracture, A or B?

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The Weber two-point discrimination test assesses innervation density and can be used to determine tactile gnosis. Testing should begin with the discriminator 5 mm apart. The patient responds as to whether one or two points are perceived. Seven out of 10 correct responses must be obtained to receive a score. Categories are as follows:

A 800 700 600

Normal: Fair: Poor: Protective: Anesthetic:

Grams

500 400 300

200 100 0 –40

–30

–20

–10

–0

Degrees

Fig. 3-12

Brand and Hollister have suggested the use of torque range of motion (TROM) to improve objectivity in measuring ROM. TROM can be performed in the clinic using a goniometer, a strain gauge, and a finger cuff. Force is applied at a right angle to the digit that is to move. One must remember to note the position of the proximal joints. A curve with a soft slope, such as curve A, changes rapidly with increased gram load and indicates that the joint should respond to treatment. However, if the joint is in a fixed joint contracture, the slope (curve B) is steep with increased loading. This may indicate that conservative treatment (e.g., splinting) may not be effective. Answer: A Hunter, Mackin, Callahan, pp. 170-174 Brand, Hollister, pp. 115-119

29. Using the Weber test, you are testing a patient with median nerve damage. The resulting score is a 12 on digits one through three. According to the normative scale, this would be rated: A. B. C. D.

Normal Fair Poor Protective

0 to 5 mm 6 to 10 mm 11 to 15 mm One point perceived No points perceived

Answer: C Clinical Assessment Recommendations, p. 79

30. A patient is referred to you with a diagnosis of wrist contusion after an MVA. The patient presents with diffuse pain throughout the wrist and forearm and multiple structures are tender on palpation. You initially address the overall pain, and the patient is now localizing pain in the central dorsal and radial dorsal zones of the wrist. Because the patient was injured when gripping a steering wheel and because of her description of pain, you suspect a possible scaphoid injury. Radiographs are retaken and unremarkable. You are now assessing for a possible SL injury. All but which of the following tests are appropriate? A. B. C. D.

Watson shift test Clenched fist X-ray SL ballottement test Linsheid test

All of the above can be used to rule out SL injury except the Linsheid test. The Linsheid test is used to detect II and III carpometacarpal (CMC) injury. The Watson Shift test is performed by applying pressure to the volar prominence of the scaphoid, which can be palpated at the base of the thenar crease as the wrist is moved from ulnar deviation (UD) to radial deviation (RD) with slight wrist flexion. When the pressure is released a positive test will elicit a painful clunk as the scaphoid returns, thus reproducing the patient’s symptoms. A clenched fist X-ray will load the SL ligament, and in the case of injury a Terry Thomas sign will be present with a gap between the scaphoid and the lunate. Finally, the SL ballottement test may be used to assess SL instability. This test involves grasping the scaphoid with the thumb and finger with one hand while stabilizing the lunate with the other. The scaphoid is then moved in a volar and dorsal direction on the lunate, and any pain or increased movement relative to the other side is noted.

3 EVALUATION

B

–50

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Skirven, Osterman in Mackin, Callahan, Skirven, et al, pp. 1105-1106 Wright, Michlovitz in Mackin, Callahan, Skirven, et al, pp. 1187-1189

31. A patient is seen for evaluation with the diagnosis of cubital tunnel syndrome. The patient complains of intermittent numbness and tingling in the volar forearm and ulnar two fingers as well as burning pain proximal to shoulder. Which of the following is the appropriate upper limb tension test (ULTT)? A. Shoulder abduction and external rotation, supination, wrist/finger/elbow extension, shoulder depression, and cervical contralateral lateral flexion B. Shoulder abduction and external rotation, either pronation or supination, wrist/small finger extension, elbow flexion, shoulder depression, and cervical contralateral lateral flexion C. Shoulder abduction and external rotation, pronation, wrist/small finger extension, elbow extension, shoulder depression, and cervical contralateral lateral flexion D. Shoulder abduction and internal rotation, pronation, wrist/thumb/index flexion, elbow extension, shoulder depression, and cervical contralateral lateral flexion

Answer B is the appropriate position for ULTT for a patient with ulnar nerve symptoms. Answer A is the appropriate test for patients with median nerve symptoms, and answer D is the appropriate position for patients with radial nerve symptoms.

TAM is helpful for doing comparison data and it provides useful information on the composite motion of a finger. The measurement is performed in the fisted position.

Answer: D

Answer: A Clinical Assessment Recommendations, p. 68

33. To determine whether the biceps head is stable in the bicipital groove, which of the following should be performed? A. B. C. D. E.

Roos test Wright’s maneuver Yergason test Elbow flexion test Valgus/varus test

The Yergason test (Fig. 3-13) is performed by having the patient fully flex the elbow. The examiner grasps the flexed elbow with one hand while using the other hand to hold the wrist. The patient should be instructed to resist motion while the examiner externally rotates the arm. At the same time, the examiner pulls the patient’s elbow into extension. This test will determine whether the head of the biceps is stable in the bicipital groove. If the tendon is not stable, the patient may experience pain or the tendon may pop out.

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Answer: B Walsh in Mackin, Callahan, Skirven, et al, p. 768

32. Total active motion (TAM) is derived by which of the following? A. Summation of flexion minus the summation of the extension deficits B. Summation of extension minus the summation of flexion C. Summation of flexion and extension D. All of the above are acceptable ways to calculate TAM

TAM is the summation of joint flexion minus the summation of joint extension deficits. For example: (MCP joint 90 degrees + PIP joint 90 degrees + DIP joint 45 degrees) - (MCP joint 0 degrees + PIP joint - 10 degrees + DIP joint - 10 degrees) = 205 degrees of TAM. Using

Fig. 3-13

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34. What is a disadvantage of using the visual analog scale (VAS)? A. It is a highly sensitive test. B. It is difficult and awkward to use. C. It has a high failure rate because patients have difficulty interpreting the instructions. D. Examiners must have experience using the test.

The VAS is performed by drawing a 10-cm line horizontally or vertically, with the ends labeled “no pain” and “pain as bad as it could be.” The patient marks the line to indicate his or her current level of pain. The test may have a high failure rate because patients may have difficulty interpreting the instructions. Completing pain assessment with supervision is recommended to ensure proper patient understanding. Answer A is an advantage of this test, but answers B and D do not apply. Other pain tests include an array of rating scales and pain questionnaires such as the McGill or Schultz pain assessment.

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The patient likely has a central disc tear of the TFCC, possibly because of early degeneration. The articular disc shear test (Fig. 3-14) is used to assess for central lesions of the TFCC. This test is performed with the patient’s elbow resting on a table and the forearm in neutral. The examiner stabilizes the radius with one hand and places the thumb of the other hand dorsally over the distal ulna while placing the radial aspect of the index PIP joint over the pisotriquetral complex volarly. The examiner then squeezes the thumb and index finger together, thus creating a dorsal glide of the pisotriquetral complex on the ulnar head and shearing of the central disc. The GRIT is a measurement of grip strength in full supination, full pronation, and neutral forearm position. The values are calculated as a ratio of supination/pronation due to the loading principle of ulnar structures

Answer: C Clinical Assessment Recommendations, p. 100

35. True or False: The temperature of the water has no effect on the results of volumetric measurements.

Answer: False King, p. 203

36. A 40-year-old woman is referred to you for ulnar-sided wrist pain. She has no history of trauma and no radiographic signs of fracture. Upon examination, her pain is localized in the ulnar aspect of the wrist and is worse with UD, grip, and pronation. No instability is detected at end range of supination and pronation. The patient is positive for the articular disc shear test, gripping rotary impaction test (GRIT), and TFCC load test. Which of the following is the likely diagnosis? A. B. C. D.

Peripheral TFCC tear Central disc tear Lunotriquetral (LT) tear Dorsal radioulnar ligament tear

Fig. 3-14

■ The articular disc shear test is a joint mobilization described by Hertling and Kessler (also known as the ulnomeniscotriquetral dorsal glide) and has been used as a provocative maneuver for assessing articular disc or triangular fibrocartilage pathology. The technique requires that the patient be seated or supine with the elbow resting on the tabletop and the forearm in a neutral vertical position. If the right wrist is to be inspected, the examiner’s left hand stabilizes the patient’s radius and hand while the examiner’s right thumb is positioned dorsally over the head of the distal ulna. The examiner’s radial side of the right index PIP joint is then placed over the palmar surface of the pisotriquetral complex. The examiner then squeezes the thumb and index finger together to produce a dorsal glide of the pisotriquetral complex on the distal ulnar head, thereby shearing the articular disc. A positive response to this test is a reproduction of the patient’s painful symptoms and/or excessive laxity in the ulnomeniscotriquetral region. (From Hertling D, Kessler RM: Management of common

musculoskeletal disorders: physical therapy principles and methods, Philadelphia, 1990, Lippincott.)

3 EVALUATION

According to a study by Theodore King in 1993, water temperature should be controlled. His study revealed statistical significance related to variation in temperature. Therefore cool or “tepid” water is recommended for accurate results (see Fig. 3-11).

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during grip with forearm rotation. If a patient has a GRIT ratio greater than 1.0 on the involved side and no greater than 1.0 on the involved side, the potential for a disc tear is high. The standard TFCC load test (Fig. 3-15) can indicate either a peripheral or central lesion. However, the patient with a peripheral tear will likely have a history of trauma and/or instability noted at end range of supination and pronation.

37. The presence of axons in the process of regeneration can be detected by which of the following? A. B. C. D.

256-Hz tuning fork Phalen’s sign Iodine test Tinel’s sign

Answer: B Skirven, Osterman in Mackin, Callahan, Skirven, et al, p. 1108 LaStayo in Mackin, Callahan, Skirven, et al, pp. 1157, 1165-1167

CLINICAL GEM: Conservative management for articular disc tears that do not produce any DRU joint instability includes an ulnar gutter splint and education to avoid functional activities that require forearm pronation and gripping.

A Tinel’s sign (Fig. 3-16) assists in predicting distal reinnervation after nerve repair. Percussion is applied along the nerve and is positive at the most distal point at which the patient has a tingling sensation. A tuning fork is used for vibratory perception testing. The iodine assessment tests the sudomotor function of a nerve to assess sympathetic return. The Phalen’s sign is a test performed to assist in the diagnosis of median nerve compression at the wrist.

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Answer: D Clinical Assessment Recommendation, p. 71 Dellon, pp. 44-45

CLINICAL GEM: Sensations during nerve regeneration may include sharp pain, shooting pain, hot and cold flashes, the sensation of water running down the arm, numbness, tingling, or no sensation at all.

Fig. 3-15

■ TFCC load test. Axial load, ulnar deviation, and rotation are applied to the wrist to detect a painful TFCC tear or ulnocarpal abutment.

(From Mackin EJ, Callahan AD, Skirven TM, et al: Rehabilitation of the hand and upper extremity, ed 5, vol 1, St Louis, 2002, Mosby.)

Fig. 3-16

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Biceps tendon rupture Partial biceps tendon tear Ulnar nerve entrapment Olecranon fracture

Answer: B McAuliffe in Mackin, Callahan, Skirven, et al, p. 1208

CLINICAL GEM: The bony landmarks of the elbow (i.e., medial and lateral epicondyles and the olecranon) should form an upside down triangle when the elbow is flexed and a straight line when the elbow is extended. Disruption of the triangle may indicate an elbow dislocation (Mackin, Callahan, Skirven, p. 1205).

3 EVALUATION

A. B. C. D.

This patient likely incurred a partial biceps tendon tear because of the unexpected extension force to his elbow, pop felt, and weakness in elbow flexion and supination. In this case, the tendon is palpable and therefore not completely ruptured. No numbness or tingling indicates ulnar nerve entrapment, and an olecranon fracture would be visible by X-ray.

38. A patient’s primary care doctor is referred for an elbow contusion. The patient’s onset of symptoms began after a blow to his flexed elbow with which he felt a pop and severe pain while playing in a football game. The patient presents with anterior pain at cubital fossa and upon MMT, 3+/5 for both supination and elbow flexion. The patient is tender at the cubital fossa and upon palpation of the biceps tendon. The patient’s AROM is -20/125 (-indicates lack of full extension), and PROM is WNL but painful with elbow extension. X-rays were taken and are unremarkable; no numbness or tingling is noted. Circumferential measurements at the elbow crease are equal bilaterally. The likely diagnosis is which of the following?

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4 NEUROANATOMY AND SENSORY REEDUCATION

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Chapter 4

Neuroanatomy and Sensory Reeducation

A. Measurement of peripheral nerve function to permit staging of the degree of compression B. Designing better questionnaires C. Instructing therapists in telephone interview techniques D. Alpha-, beta-, and meta-analyses

Outcome studies are in the forefront of analysis techniques to study the results of peripheral nerve decompression. Outcome is foremost determined by the initial stage of the nerve compression, and this requires preoperative measurements. Repeating these measurements after peripheral nerve surgery permits statistical analysis of results of the sensory and motor improvement by using a numerical grading scale and nonparametric statistics, thus permitting a different view of outcomes from the questionnaires. Meta-analysis is used to arrive at a conclusion from many studies of a single operation and is helped if all the patients in the studies have been staged preoperatively so that similar groups can be compared. Answer: A Dellon, pp. 229-240

2. A patient is evaluated for complaints of numbness in the thumb and index finger after a carpal tunnel decompression. Another nerve might be compressed causing the numbness. What is the compression site?

A. Deep head of the pronator teres or the lacertus fibrosis B. Arcade of Froshe C. Medial head of the triceps D. Fascia between the brachioradialis and extensor carpi radialis longus

Compression of the radial sensory nerve in the distal third forearm can cause numbness in the index finger and thumb, but the numbness would occur on the dorsal surface of the thumb and index. The site of compression occurs where the nerve exits from subfascial to subcutaneous, between the brachioradialis and the extensor carpi radialis longus.

1. The current approach to evaluating the success of decompression of a peripheral nerve requires which of the following?

Answer: D Dellon, Mackinnon, pp. 199-205

3. A 36-year-old female typist complains of numbness in the little and ring finger in both of her hands. On physical examination, her pinch and grip strength are normal, but she has increased cutaneous pressure threshold for static twopoint discrimination at 3 mm. What would the most appropriate treatment be? A. Ulnar nerve surgical decompression B. Dynamic splinting at work C. Night splinting with the elbow between 10 and 30 degrees of flexion D. Three months of short-term disability

The treatment of nerve compression should be determined by the stage of degree of nerve compression. 67

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CHAPTER 4 ■ Neuroanatomy and Sensory Reeducation

Neurosensory and motor testing permit staging. If twopoint discrimination is still normal and there is little weakness, the staging is “mild” in degree of compression, and nonoperative regimens should be used. Night splinting is a conservative treatment technique.

Meissner’s corpuscles– light pressure

Epidermis

Dellon, 2000, pp. 127-136 Dermis

The treatment of nerve compression should be determined by the stage of degree of nerve compression. Neurosensory and motor testing permit staging. If two-point discrimination is abnormal, axonal loss has occurred, and according to Dellon, the degree of compression is too advanced for conservative treatment, thus indicating surgical intervention. The surgical intervention in this case is a submuscular ulnar nerve transposition. Answer: A Dellon, 2000, pp. 127-136

5. Which sensory receptor is responsible for detecting a sensation of a gentle breeze blowing against the skin? Ruffini end organs Pacinian corpuscle Merkel cell None of the above

The Pacinian corpuscle is a sensory receptor that is innervated by a single, quickly adapting nerve fiber. The Pacinian corpuscle is large and located in subcutaneous tissue. It is extremely sensitive to mechanical stimuli and therefore is responsible for detecting a very gentle breeze blowing across the skin. Answer: B Dellon, 1997, p. 20

Refer to Fig. 4-1

Subcutaneous tissue Ruffini’s corpuscles– tension

Fig. 4-1

Pacinian corpuscles– vibration

■ From Lindsay DT: Functional human anatomy, St Louis, 1996,

Mosby.

6. 30-Hertz vibration is perceived by which of the following? A. B. C. D.

Slowly adapting Ruffini end organs Quickly adapting Meissner corpuscles Quickly adapting Pacinian corpuscles Slowly adapting Merkel cells

30 Hertz (Hz) vibration and movement are perceived by quickly adapting A-ß fibers known as Meissner corpuscles. 256-Hz vibration and movement are perceived by the quickly adapting A-ß fibers known as Pacinian corpuscles. Both receptors are found in glabrous (nonhairy) skin and are encapsulated (see Fig. 4-1).

A. Submuscular ulnar nerve transposition B. Dynamic splinting while at work C. Night splinting with the elbow between 10 and 30 degrees of flexion D. Three months of short-term disability

Free endings– mechanical, thermal, pain

Answer: C

4. A 36-year-old female typist complains of numbness in the little and ring finger in both of her hands. On physical examination, her pinch and grip strength are abnormal, but she has increased cutaneous pressure threshold for static two-point discrimination at 8 mm. What would be the most appropriate treatment?

A. B. C. D.

Merkel’s endings– pressure

Answer: B Dellon, 1997, pp. 10, 11

7. Constant-touch pressure is perceived by which of the following? A. B. C. D.

Large Large Large Large

myelinated myelinated myelinated myelinated

A-b fibers slowly adapting A-b fibers quickly adapting A-d fibers quickly adapting A-a fibers slowly adapting

A-ß fibers are called neuroreceptive afferents, which may be either slowly or quickly adapting nerve fibers. Constant-touch pressure is perceived by slowly adapting, large, myelinated A-ß fibers. Constant touch is perceived by the Merkel cells found in the glabrous skin and the Ruffini end organs in hairy skin.

Answer: A

CLINICAL GEM: The following is a quick reference chart to correlate receptors, functions, and applicable tests: Specialized receptors Merkel cell

Pacinian corpuscle

Meissner corpuscle

Functions

Applicable tests

Constant-touch pressure

Semmes-Weinstein monofilament Static two-point discrimination Tuning fork Tuning fork

256-Hertz Movement and vibration 30-Hertz Movement and vibration

Tuning fork Moving two-point discrimination

8. Which of the following types of sequential neurosensory testing determines the earliest sign of nerve compression? A. Cutaneous thermal threshold B. Cutaneous pressure threshold for one-point static touch with nylon monofilaments with Seems Weinstein monofilament (SWM) C. Cutaneous vibratory threshold D. Cutaneous pressure threshold for static two-point discrimination with pressure-specified sensory device (PSSD)

A. B. C. D.

Answer: D Dellon, 1999, pp. 697-715

9. You are treating a 41-year-old woman who sustained a median nerve injury at the wrist level. A nerve repair was performed. The patient’s repair was protected for 3 weeks; next, range of motion and early sensory reeducation were initiated. You would like to progress to object recognition or late-phase sensory reeducation. Which would be the best screening test for

Perception of pinprick 256-Hertz vibration Detection of hot or cold 30-Hertz vibration

The recovery sequence begins with pain and temperature because these sensations are perceived through unmyelinated and thinly myelinated fibers. Next, the large myelinated fibers begin to receive 30 Hz by the Meissner corpuscles, which are easy to reinnervate because any of the nine different nerves may innervate this receptor from any direction. After this, moving touch is perceived, followed by constant touch. Next, a 256-Hz stimulus is perceived by means of a single, quickly adapting nerve fiber, which can enter through either end of the large, football-shaped Pacinian corpuscle. When your patient can detect 256 Hz, she is ready for object recognition or late-phase reeducation. If you begin object recognition before the detection of 256 Hz, it will most likely be uneventful, and you and the patient will become frustrated. Answer: B Dellon, 1997, pp. 20, 249-250, 262

CLINICAL GEM: The following is a quick reference list of the order of sensory return. • • • • • • • •

Thermal thresholds are the last to change with nerve compression, whereas those for pressure and touch are the earliest to change. In a regression analysis with a neurosensory device that measures the pressure required to discriminate one from two static touch stimuli, the earliest sign of nerve compression was determined to be the change in the threshold for static two-point discrimination.

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determining whether your patient is ready to start late-phase reeducation?

Dellon, p. 10


Pain and temperature 30-Hz vibration Moving touch Constant touch 256-Hz vibration Touch localization Two-point discrimination Stereognosis

10. After an anterolateral surgical approach to the forearm, a patient experiences numbness on the lateral (radial) aspect of his forearm. Which structure is most likely affected? A. B. C. D.

Anterior interosseous nerve Axillary nerve Posterior interosseous nerve Lateral antebrachial cutaneous nerve


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The lateral antebrachial cutaneous nerve crosses the elbow and enters the forearm between the biceps and the brachialis. This nerve is at risk in the anterolateral and anterior surgical approaches to the forearm.

A. B. C. D.

Cervical stenosis Peripheral neuropathy, small fiber type Bilateral carpal and cubital tunnel syndrome Syrinx

Answer: D Hoppenfeld, de Boer, pp. 93, 96

Refer to Fig. 4-2

Lat. brachial cutaneous nerves upper

A syrinx is a cyst in the spinal canal. It usually grows anteriorly. The posterior long tracts, which transmit perception of touch and pressure, are preserved. The ventral motor neurons are damaged early, resulting in intrinsic muscle wasting when the syrinx is located in the cervical spine region. The anterolateral spinal thalamic tracts are usually damaged early in the course of this process, giving deficits in the perception of pain and temperature.

Cephalic v.

Lat. brachial cutaneous n., lower

Intercostobrachial n.

Answer: D Dellon, 1997, pp. 10-15

Medial brachial cutaneous n.

Basilic v. Medial antibrachial cutaneous n. Lat. antibrachial cutaneous n. Median cubital v.

12. A 30-year-old man presents with inability to flex the tip of the thumb and index finger. Physical examination also identifies weakness in the deltoid. He has no history of injury; rather, the onset was sudden and associated with pain in the shoulder. He can recall working out in the gym the week before symptoms occurred. What is his likely diagnosis?

Post. antibrachial cutaneous n.

Cephalic v.


11. A 42-year-old man complains that his hands have become weak, and as an auto mechanic he has burned and sometimes cut his fingertips without knowing it until he looked at his fingers. On physical examination, he has intrinsic muscle weakness, and some wasting of the first dorsal interosseous, with normal twopoint discrimination in his index and little fingers. What is his most likely diagnosis?

A. B. C. D.

Anterior interosseous nerve (AIN) syndrome Quadrangular space syndrome Schwanoma, upper trunk of brachial plexus Parsonage-Turner syndrome

Anterior interosseous nerve palsy occurs most often in the setting of trauma, or comes on slowly with no history of pain. Additionally, AIN syndrome has no correlation with shoulder pain. When the onset of palsy is rapid and is associated with pain but no trauma, an inflammatory plexopathy such as Parsonage-Turner syndrome must be considered. Electrodiagnostic testing is crucial to document a “spotty” pattern of plexus muscle involvement. The natural history is most often spontaneous resolution.

Basilic v.

Answer: D Wong, Dellon, pp. 536-539


13. A 21-year-old wrestler has pain in his anterior shoulder after having a shoulder arthroscopy approach to repair his rotator cuff. His range of shoulder motion is limited by anterior shoulder pain. He can localize the pain to the site of the arthroscopy portal anteriorly. What is his most likely diagnosis? A. B. C. D.

Axillary nerve injury, cutaneous branch Neuroma supraclavicular nerve Bursitis Acromioclavicular impingement

15. In what is the cell body of the sensory neuron located? A. B. C. D. E.

Spinal cord Dorsal root ganglion Brain A and B are correct All are correct

The most basic unit of the nervous system is the neuron. The neuron is the functional and structural unit that initiates and conducts impulses. In the peripheral nervous system, there are motor and sensory neurons. The cell body of the motor neuron is located in the ventral horn of the spinal cord. The cell body of the sensory neuron is located in the dorsal root ganglion, outside the central nervous system. The sensory neuron’s axon extends to skin.

CLINICAL GEM: A group of lesions, categorized as idiopathic or cryptogenic brachial plexus neuritis, actually presents a spontaneous entrapment in the brachial plexus. Many of these lesions fall into the category of what Spinner called the Parsonage-Turner syndrome (Rockwood, Matsen, p. 143).

Answer: B Dellon, 1997, p. 2

Refer to Fig. 4-3

The supraclavicular nerve, from C3-C5, innervates the region of the anterior shoulder skin that is often the site for orthopedic surgery intervention. A painful scar can be caused by a neuroma of these little nerve branches. The sensory portion of the axillary nerve innervates the lateral deltoid region.

Dorsal root

Dorsal root ganglion

Sensory ending

Answer: B Mackinnon, Dellon, p. 68

14. True or False: Pain receptors are in encapsulated cells.

Pain and temperature are perceived by free nerve endings. Receptors for pain and temperature are located on our body surface area through the skin. Pain and temperature receptors are thinly myelinated A-d fibers and unmyelinated C fibers, which conduct at a slow rate compared with the encapsulated cells such as A-b sensory and A-a motor fibers, which are thickly myelinated.

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Answer: False Dellon, 1997, pp. 6, 9-13

Blood vessel

Ventral root Spinal segment

Viscus

Skeletal muscle (motor)

Sensory Motor

Fig. 4-3

16. True or False: Schwann cells are located in the central nervous system.


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cular) epineurium is the connective tissue lying between the fascicles facilitating gliding. The structure that surrounds the entire nerve is called the external epineurium.

Schwann cells are located in the peripheral nervous system and create the myelin sheath around the axon. For axons to conduct fast impulses, an insulation or myelin is required. Myelin is a lipoprotein. The slower conducting axons within the peripheral nervous system are not myelinated. Schwann cells serve an extremely important functional role for the peripheral nervous system. They make nerve growth factor, which enables the peripheral nerve to regenerate. The central nervous system does not have Schwann cells; the analogous cells in this system are oligodendrocytes and astroglia.

Answer: True Dellon, 1997, p. 6 Brushart in Green, Hotchkiss, Pederson, p. 1382 Butler, p. 8

Refer to Fig. 4-4

Vessel

Answer: False

Epineurium

Dellon, 1997, p. 4

Perineurium Endoneurium

17. Match Sunderland’s five numerical classifications of peripheral nerve injury with their definitions. Degree

Nerver fiber Endoneurium Perineurium

Fascicle

Group of fascicle

Epineurium

1. 2. 3. 4. 5.

First Second Third Fourth Fifth

Definition

Fig. 4-4 ■ Cross-section of normal peripheral nerve. Peripheral nerve fibrosis of the epineurium constricts the nerve anatomy and metabolism of the axon flow, thus resulting in altered functional and sensory patterns. ■ (Copyright, Elizabeth Roselius, 1993. From Wilgis EFS, Brushart TM: Nerve repair and grafting. In Green DP, Hotchkiss RN, eds: Operative hand surgery, vol 2, ed 3, New York, 1993, Churchill Livingstone. Used with permission.)

A. Transection of the entire trunk B. Local conduction block with minimal structural

disruption

CLINICAL GEM: The fascicle is the smallest unit of nerve structure that can be manipulated surgically.

C. Disruption of the axon, endoneurium, and per-

ineurium. The epineural tissue is spared. D. Disruption of axon only, leaving the endoneurium

intact; a neuroma-in-continuity E. An intact perineurium surrounding a disruption of

Answers: 1, B; 2, D; 3, E; 4, C; 5, A

19. The perineurium has the following function: A. B. C. D.

Protects the contents of the endoneural tubes Surrounds each fascicle Acts as a diffusion barrier All of the above

Skirven, Callahan in Mackin, Callahan, Skirven, et al, p. 601 Butler, p. 176

18. True or False: The epineurium surrounds the entire nerve.

A nerve is composed of nerve fibers bound together in bundles or fascicles. The perineurium is the connective tissue layer surrounding the fascicle. The endoneurium is the space within the fascicle. The internal (interfasci-

The perineurium is a strong, elastic tissue that surrounds each fascicle and protects the contents of the endoneural tubes. It has an important role as a diffusion barrier. The perineurium aids in keeping certain substances out of the intrafascicular environment (see Fig. 4-4).

the axon and endoneurium

Answer: D Butler, pp. 8, 23-24


20. Match the medical terminology with the sympathetic function for that term.

73

the thumb and thenar eminence. She also has abnormal sensibility in her index finger and thumb. What is her most likely diagnosis?

Terminology 1. 2. 3. 4.

Vasomotor Sudomotor Pilomotor Trophic

A. B. C. D.

Recurrent carpal tunnel syndrome Radial sensory nerve compression Pronator syndrome C7 Radiciculopathy

Sympathetic Function Gooseflesh response Hair growth and nail changes Skin color and skin temperature changes Sweat

Answers: 1, C; 2, D; 3, A; 4, B Malick, Kasch, p. 19

21. How does the median nerve usually enter the forearm? A. B. C. D.

Superficial to the lacertus fibrosis Between the two heads of the supinator Between the two heads of the pronator teres Posterior to the brachial artery

The median nerve enters the forearm between the two heads of the pronator teres, deep to the biceps aponeurosis. Answer: C

With the pronator syndrome, there is compression of the median nerve proximal to the wrist. The palmar cutaneous branch of the median nerve arises proximal to the wrist, and it innervates the base of the volar thumb and the thenar eminence. Abnormal sensibility will occur at the base of the thumb and thenar eminence only when the compression site is proximal to the wrist due to pathology of the palmar cutaneous branch. Palmar cutaneous branch injury can occur when this branch has been cut by the surgeon’s carpal tunnel incision.

A. B. C. D.

Answer: C Rosenberg, Conolley, Dellon, 2001, pp. 258-265

CLINICAL GEM: A quick way to rule out carpal tunnel syndrome is to assess the thenar eminence. If the sensation is impaired in this area, carpal tunnel is ruled out. The palmar cutaneous branch branches off the main nerve (median nerve) before it passes below the retinaculum, resulting in impaired sensation in the thenar eminence with proximal compression such as in pronator syndrome.

Hoppenfeld, de Boer, p. 121

CLINICAL GEM: Each major peripheral nerve enters the forearm through a two-headed muscle: the median nerve enters through the pronator teres, the radial nerve through the supinator, and the ulnar nerve through the flexor carpi ulnaris.

22. One year after a carpal tunnel decompression, a 50-year-old woman is still complaining of numbness in the thumb and index finger. Her scar is not tender. She has an increased cutaneous pressure threshold in the volar base of

23. After ulnar nerve transposition, the patient complains of pain in the medial aspect of the elbow. On examination, the little and ring finger have normal sensibility, but the skin around the incision is dysesthetic and has a painful trigger point. The most likely cause for these observations is which of the following? A. Recurrent ulnar nerve compression B. Injury to the ulnar nerve C. Neuroma of the palmar cutaneous branch of the median nerve D. Neuroma of the medial antebrachial cutaneous nerve


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The medial antebrachial cutaneous nerve has a posterior branch, which crosses the site for the incisions used for most ulnar nerve transpositions. A painful scar after this surgery must be considered as having a neuroma of this nerve. If the little and ring finger are also numb, recurrent ulnar nerve compression may also be present, as the medial antebrachial cutaneous nerve does not go to the little and ring finger. Answer: D Dellon, 2002, pp. 158-160

Refer to Fig. 4-2

24. A woman sustains an electrical injury while cleaning her living room rug with a rented rug washing machine. The electric shock knocks her to the floor and leaves her right arm tingling. This tingling persists for 3 months and disturbs her sleep, and her hand becomes clumsy. She most likely has which of the following? A. B. C. D.

Reflex sympathetic dystrophy Cervical disc injury at C6, C7, and C8 Compression of the median and ulnar nerve Thoracic outlet syndrome

Electrical energy travels through the body by the line of least resistance, usually muscle and blood vessels. At the wrist and elbow, there is little muscle mass, and the resistance increases, which means there is increased heat energy at these locations. This places the medial and ulnar nerves at risk for compression. Answer: C Smith, Muehlberger, Dellon, pp. 137-144

25. When you put on a pair of gloves, which receptor perceives stimuli until the glove is removed? A. B. C. D.

Merkel cells Meissner corpuscles Free nerve endings Pacinian corpuscles

The large, myelinated, A-b slowly adapting fibers perceive the constant touch of your gloves. The Merkel cells begin to transmit impulses immediately and continue to transmit them until you remove the gloves.

74

Answer: A Dellon, 1997, p. 10

26. A 29-year-old woman who is a professional flute player is referred to you for evaluation and treatment. Her complaints range from aching shoulders to coldness and numbness in the whole hand and occasional tingling in the little and ring fingers. The evaluation reveals no intrinsic wasting. The referring physician has ruled out carpal tunnel syndrome, cubital tunnel syndrome, tumors, temporomandibular joint pathology, and cervical disc disease. Which exercise program would you choose? A. Stretching the wrist and elbow muscles and strengthening the pectoralis minor and scalene muscles B. Stretching the middle and lower trapezius and strengthening the pectoralis major and minor muscles C. Stretching the pectoralis minor, upper trapezius, and scalene muscles and strengthening the middle and lower trapezius, serratus anterior, and levator scapulae muscles D. A and B E. B and C

After careful examination and discussion with the referring physician, you would conclude that this patient has thoracic outlet syndrome. If the term “thoracic outlet” is taken literally, confusion may occur. Some authors and clinicians refer to thoracic outlet syndrome as brachial plexus compression in the thoracic inlet; thoracic outlet syndrome, by name, implies that the diaphragm is restricted because the thoracic outlet is the region between the thorax and the abdomen. Thoracic outlet syndrome is accepted among surgeons and neurologists in the following two situations: 1) when the patient presents with a cervical rib, which can cause either subclavian artery or vein occlusion; or 2) when the patient presents with intrinsic muscle wasting and numbness of the little finger. The latter is confirmed with electromyography. These two conditions are uncommon and require surgical intervention. Fortunately, the majority of cases do not fall into these categories and can be managed conservatively. In this case study, the therapist should observe the patient playing her flute, adjust her practice schedule, change her positioning, and teach exercises to strengthen the patient’s shoulder girdle muscles and to relax or stretch the other musculature. The therapist should design a program to strengthen the middle and


lower trapezius, serratus anterior, and levator muscles while stretching or relaxing the pectoralis minor, upper trapezius, and scalene muscles. One way to stretch the pectoralis minor and strengthen the serratus is to perform wall push-ups while facing a corner, using both walls.

75

Nerve fiber

Diffusion

Answer: C

+

Na+

Na

Dellon, 1997, pp. 506-539 Pump

CLINICAL GEM: A helpful reference book to recommend to musicians with musculoskeletal pathologies is Richard Norris: The Musician’s Survival Manual: A Guide to Preventing and Treating Injuries in Instrumentalists, St Louis, 1993, International Conference of Symphony and Opera Musicians.

Diffusion

K+

Pump

27. True or False: The concentration of potassium is higher on the inside of a cell in normal muscle and nerve tissue.

To understand the physiology of normal cell excitability, it is important to understand active and passive diffusion through the cell membrane. Muscle and nerve cells are encased in a membrane that separates a charge from the inside and the outside of a cell. This charge has a resting membrane state of approximately -60 millivolts (MV). The inside of the cell is negative in comparison to the outside of the cell. In normal muscle and nerve tissue, potassium (K+) ions are higher on the inside of the cell, and sodium (Na+) is higher on the outside of the cell. The concentration differences are maintained by an active pump across the membrane. This pump helps the cell eliminate sodium ions while receiving potassium ions. In addition, a passive diffusion of ions across the membrane attempts to equalize the ion concentration. Answer: True Hunter, Mackin, Callahan, pp. 1508-1509

Refer to Fig. 4-5

28. A 32-year-old male sustained a median nerve laceration at the level of the elbow 6 months ago. The nerve was repaired. Manual muscle testing revealed a 4+/5 for the pronator teres and a 3/5 for the flexor digitorum superficialis. Which muscle would you expect to return next?

K+

+

–

Fig. 4-5

■ From Hunter JM, Mackin EJ, Callahan AD: Rehabilitation of the hand: surgery and therapy, ed 4, St Louis, 1995, Mosby.

A. Flexor digitorum profundus to the first and second digits B. Flexor digitorum profundus to the second and third digits C. Pronator quadratus D. Palmaris longus E. Palmaris brevis

The median nerve (Fig. 4-6, B) arises from the lateral cord (C6, C7) and the medial cord (C8, T1) of the brachial plexus. The median nerve enters the forearm between the two heads of the pronator teres, innervating them, and then innervates the flexor carpi radialis. The next muscle innervated along the course of the median nerve is the palmaris longus, followed by the flexor digitorum superficialis, the flexor digitorum profundus to the index and middle finger (second and third digits), the flexor pollicis longus, and the pronator quadratus. The first muscle that the nerve innervates after crossing the wrist is the abductor pollicis brevis, followed by the opponens pollicis and the flexor pollicis brevis; the nerve terminates in the first and second


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Triceps long head Triceps lateral head

Triceps medial head

Brachioradialis E. carpi radialis longus E. carpi radialis brevis

Anconeus Supinator E. digitorum communis E. digiti minimi E. carpi ulnaris Abd. pollicis longus E. pollicis longus E. pollicis brevis E. indicis proprius

A

Pronator teres F. carpi radialis Palmaris longus F. digitorum superficialis (4)

B

F. digitorum profundus II and III F. pollicis longus

Pronator quadratus

Abd. pollicis brevis F. pollicis brevis (superficial) Opponens pollicis Lumbrical II and III

F. carpi ulnaris (1)

C

F. digitorum Profundus IV and V F. carpi ulnaris (2)

Palmaris brevis Add. digiti minimi Opponens digiti minimi F. digiti minimi Lumbrical IV and V

Fig. 4-6

F. pollicis brevis (deep) Add. pollicis

Interossei

■ Terminal branches of the (A) radial, (B) median, and (C) ulnar nerves. (Redrawn from the American Society for Surgery of the Hand: The hand, examination and diagnosis, Aurora, CO, 1978, The Society.)


Answer: B Hunter, Mackin, Callahan, pp. 70, 765 Aulicino in Mackin, Callahan, Skirven, et al, p. 137 Skirven, Callahan in Mackin, Callahan, Skirven, et al, p. 605 Colditz in Mackin, Callahan, Skirven, et al, p. 630

CLINICAL GEM: The following is a quick reference to median nerve innervation: Number of muscles per group

Specific muscles

Four muscles

1. 2. 3. 4.

Three muscles

1.

Four muscles

2. 3. 1. 2. 3. 4.

Pronator teres Flexor carpi radialis Palmaris longus Flexor digitorum superficial Flexor digitorum profundus (index and middle) Flexor pollicis longus Pronator quadratus Abductor pollicis brevis Opponens pollicis Flexor pollicis brevis Lumbricals (one and two)

Anatomical location Forearm

Forearm (anterior interosseous nerve)

Wrist, hand

CLINICAL GEM: At the mid-forearm, the median nerve branches into the AIN. The AIN innervates the flexor digitorum profundus to the index and middle fingers, the flexor pollicis longus, and the pronator quadratus, and then innervates the volar wrist capsule. When the AIN is damaged, a patient cannot form an O with the thumb and index fingers (see Fig. 18-23). 29. An 18-year-old male sustained an injury to the posterior cord of the brachial plexus. Initially, return of the triceps was observed. Eight months later the patient is able to radially deviate his wrist and slight forearm supination is observed. Which muscle would you expect to return next? A. B. C. D.

Brachioradialis Extensor carpi ulnaris Extensor digitorum communis Extensor indicis

The radial nerve is a continuation of the posterior cord of the brachial plexus. Its roots emerge from C6, C7, C8, and T1 levels. The radial nerve innervates the triceps, anconeus, and brachioradialis as it winds posteriorly on the humerus. Next, the motor branch innervates the extensor carpi radialis longus and extensor carpi radialis brevis and enters the forearm between the two heads of the supinator. At this point, the motor and sensory nerves divide into the superficial sensory branch and the deep branch. There is controversy as to when the radial nerve becomes termed the posterior interosseous nerve (PIN). In about 55% of extremities, the radial nerve supplies the extensor carpi radialis brevis; in the other 45%, the extensor carpi radialis brevis is supplied by the PIN. The PIN supplies the supinator, extensor digitorum communis, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and extensor indicis proprius (see Fig. 4-6, A).

lumbricals. Answer A, the first and second digits, refers to the thumb and index fingers.

77

Answer: C Tubiana, Thomine, Mackin, p. 266 Aulicino in Mackin, Callahan, Skirven, et al, p. 137 Colditz in Mackin, Callahan, Skirven, et al, p. 630

CLINICAL GEM: The following is a quick reference to radial nerve innervation: Muscle

Nerve

Triceps Anconeus Extensor carpi radialis longus Extensor carpi radialis brevis

Radial nerve

Supinator Extensor digitorum communis Extensor digiti minimi Extensor carpi ulnaris Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis proprius

Radial nerve or posterior interosseous nerve Posterior interosseous nerve

CLINICAL GEM: With respect to nerve innervation order, some authors place the anconeus muscle after the triceps and others place it after the extensor carpi radialis brevis. 30. A patient with Type II diabetes complains of numbness in the right thumb, index, and middle finger, and has night-time awakening. Early thenar wasting is present, and static twopoint discrimination is 8 mm in the thumb. The most likely diagnosis is which of the following?


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A. B. C. D.


Diabetic neuropathy only Diabetic neuropathy with carpal tunnel syndrome Diabetic neuropathy with ulnar nerve compression Carpal tunnel

Carpal tunnel syndrome is present in more than 20% of diabetics with neuropathy. When neuropathy is present, there is a symmetrical sensory change in all fingers of both hands. When there is asymmetry in either ulnar versus median or left versus right, and a positive Tinel sign is present, it is likely that a superimposed nerve compression exists in the patient with diabetes. Answer: B Aszmann, Kress, Dellon, pp. 816-822

31. After a nerve repair at the wrist, the best way to evaluate early success of the surgery and whether reoperation and nerve grafting are indicated is to do which of the following? A. B. C. D.

Electromyography (EMG) Nerve conduction velocity studies Neurosensory testing Distal latency with inching technique

Traditional electrodiagnostic studies are painful to most patients, while neurosensory testing is not. For this reason alone, neurosensory testing should be the method of choice. Remyelination is never complete after a nerve repair and is not a good indication. Sensory recovery occurs before motor recovery, and so tests of motor latency and EMG will lag behind those of cutaneous pressure measurements. Answer: C Cohen, Dellon, pp. 501-505

32. During sensory nerve regeneration, the first large fiber (group A-b) sensation to recover is that of movement. Which of the following tests of sensibility cannot measure this perception threshold? A. B. C. D.

Nylon monofilament (SWM) Pressure-Specified Sensory Device (PSSD) Tuning fork at 30 Hz Stroking the fingertip pulp with examiner’s finger

The nylon monofilament is designed to flex at a certain force and is held still while that force is applied and does not assess perception of movement. Vibration and stroking the fingertip pulp stimulates the quickly adapting fibers that transmit perception of movement. The PSSD can measure both one point moving threshold, which is the first perception to occur after a nerve repair, and moving two-point discrimination, which recovers later in the course of nerve regeneration, as more nerve fibers reach the target skin territory.

78

Answer: A Cohen, Dellon, pp. 501-505

Refer to Fig. 4-7

33. A 56-year-old woman sustained an ulnar nerve laceration just distal to the medial epicondyle of the humerus. The patient presented 2 months after her initial injury. You noted full wrist flexion and ulnar deviation with gravity eliminated. The patient was unable to flex the wrist against gravity, and no other ulnarinnervated muscles were functioning. A month later you note that the patient can ulnarly deviate the wrist and flex the wrist against gravity and can tolerate minimal resistance. Knowing the course of the ulnar nerve, which function/motion would indicate that the ulnar nerve is regenerating? A. B. C. D.

Having Having Having Having

the the the the

patient patient patient patient

spread the fingers apart bring fingers back together perform a hook fist pinch a piece of paper

The ulnar nerve arises from the medial cord of the brachial plexus. Its roots emerge from C7, C8, and T1. The ulnar nerve does not innervate any part of the upper extremity until it crosses the elbow and enters the forearm between the two heads of the flexor carpi ulnaris, followed by the flexor digitorum profundus to the fourth and fifth digits. If your patient is able to perform a hook fist (flexing the tips of the fingers), this would indicate regeneration of the ulnar nerve to the flexor digitorum profundus. The ulnar nerve then crosses the wrist and innervates the following: the abductor digiti minimi, the opponens digiti minimi, the flexor digiti minimi, the third and fourth lumbricals, the palmar interossei, the dorsal interossei, the deep head of the flexor pollicis brevis, and the adductor pollicis. The order of innervation after the ulnar nerve crosses the wrist varies according to different authors (see Fig. 4-6, C).


79

myelinated fibers, large fiber regeneration occurs. The first perception to recover is that of one-point moving touch, then one-point static touch, then two-point moving touch, and finally two-point static touch. Answer: B Cohen, Dellon, pp. 501-505

CLINICAL GEM: According to Dellon’s studies, the first parameter to become abnormal with chronic nerve compression is the pressure threshold for static two-point discrimination.

■ From Hunter JM, Schneider LH, Mackin EJ, et al: Rehabilita-

tion of the hand, St Louis, 1978, Mosby.

Answer: C Tubiana, Thomine, Mackin, p. 275 Hunter, Mackin, Callahan, p. 70 Aulicino in Mackin, Callahan, Skirven, et al, p. 137 Colditz in Mackin, Callahan, Skirven, et al, pp. 624-626

CLINICAL GEM: The following is a quick reference to ulnar nerve innervation: Flexor carpi ulnaris Flexor digitorum profundus (fourth and fifth digits)

Forearm

Abductor digiti minimi

Wrist and hand muscle (order varies) NOTE: Hunter, Mackin, and Callahan indicate that the first dorsal interosseus is the last muscle to be innervated.

Opponens digiti minimi Flexor digiti minimi Lumbricals (three and four) Interossei (palmar and dorsal) Flexor pollicis brevis (deep) Adductor pollicis

34. Which of the following potential testing modalities is the first to recover after a nerve repair? A. B. C. D.

One-point static touch One-point moving touch Two-point static touch Two-point moving touch

After recovery of pain and temperature perception, which is caused by the small unmyelinated and small

35. At about 6 months after median nerve reconstruction with a neural conduit at the level of the wrist, the patient complains of aching and pain in the palm and hand. The scar, however, is not tender. Which of the following nerve conduits would require removal because it is the likely cause of nerve compression? A. B. C. D.

Vein Silicone tube Neurotube (polyglycolic acid, bioabsorbable) Muscle

Silicone tubes used as conduits are not absorbed; they are permanent. Silicone tubes can become a source of nerve compression and indeed in experimental models are used to create nerve compression. Bioabsorbable nerve conduits such as the polyglycolic acid neurotube are absorbed and cannot cause nerve compression. Compression of nerve by vein and muscle has not been reported to date.

Fig. 4-7

Answer: B Dellon, 1994, pp. 271-272

36. The presence of an ipsilateral Horner’s syndrome in a patient with a traction lesion of the brachial plexus indicates which of the following? A. B. C. D.

Infraganglionic lesion involving C8 Supraganglionic lesion involving T1 Dorsal root injury at C8 Cervical stenosis at C8-T1


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Whitenack, Hunter, Read in Mackin, Callahan, Skirven, et al, p. 727 Koman, Smith, Smith in Mackin, Callahan, Skirven, et al, p. 1700

37. You are treating a patient after ulnar nerve repair at the wrist; no tendons were involved. How long should the nerve be protected by immobilization? A. B. C. D.

1 7 4 6

day to 10 days weeks to 8 weeks

After nerve repair, immobilization should be required for approximately 7 to 10 days. However, some authors promote 3 weeks of protection after nerve repair before mobilization is initiated. During the period of nerve regeneration, therapy should focus on keeping the affected area supple, mobile, and ready to accept the growing axons. Sensory reeducation programs should be initiated when appropriate reennervation occurs. It is the therapist’s responsibility to ensure end organ protection through splinting, gentle range of motion, massage modalities, and protective techniques to maximize functional outcome. Answer: B Hunter, Mackin, Callahan, p. 622 Hayes, Carney, Wolf, et al, in Mackin, Callahan, Skirven, et al, p. 655

38. True or False: The suprascapular nerve arises from the middle trunk of the brachial plexus.

The suprascapular nerve arises from the upper trunk, from C5 and C6 nerve roots. The suprascapular nerve innervates the supraspinatus and infraspinatus muscles, and sensation to the shoulder capsule (Fig. 4-8). Answer: False Bednar, Wurapa in Mackin, Callahan, Skirven, pp. 1307-1308

Hansen’s disease, also known as leprosy, is an infectious bacterial disease. This disease damages the nerves (especially in the limbs and facial areas) and can cause skin damage. If the disease is caught early, severe deformity can be prevented. Damage occurs to the peripheral nerves and this causes most of the deformities seen in patients with Hansen’s disease.

Answer: B

39. True or False: Hansen’s disease belongs in the family of peripheral nerve diseases and disorders.

Answer: True Bell-Krotoski, p. 133

40. The lower two thirds of the dermatome that covers the deltoid muscle are derived from which nerve root? A. B. C. D. E.

C4 C5 C6 C7 C8

The deltoid is motored by the axillary nerve, which is derived from the brachial plexus roots C5 and C6. The cutaneous nerve supplying sensory innervation to the skin over the lower two thirds of the deltoid is derived from the superior lateral brachial cutaneous nerve (C5 nerve root), branching from the axillary nerve.

Horner’s syndrome is contraction of the pupil, partial ptosis (drooping), enophthalmos (recession of eyeball into orbit), and sometimes loss of sweating over the affected side of the face. An ipsilateral Horner’s syndrome in a patient with a brachial plexus traction injury indicates a supraganglionic lesion involving the T1 nerve root, through which sympathetic fibers enter the plexus. A poor prognosis is associated with root damage at this level.

Answer: B Bednar, Wurapa in Mackin, Callahan, Skirven, et al, p. 1308 Butler, p. 111

Refer to Fig. 4-9

41. Which of the following functions is not mediated from the sympathetic nervous system (SNS)? A. B. C. D. E.

Sudomotor Vasomotor Trophic Pilomotor All of the above are mediated from the SNS.

The SNS mediates vasomotor (skin color and skin temperature), sudomotor (sweat), pilomotor (gooseflesh), and trophic (skin texture, soft-tissue atrophy, nail

8

v. C er

ot

o

oot VI R

o IR VII

rv.

Phrenic N. Diaphragm

14 Medial Cord

13

12 Lateral 17O u

22

19

23 SubscapuLongus Thoracic N. Nerve of Bell. 15 Lat. and Med. lar N. Ant. Thoracic N. Serratus Magnus

le dd

Trun k

21

From 2nd Thor. Two pathways given here, but only schematic.

To Cervical Sympathetic 1st Thoracic Conc Dilator Pupilae Lev Palpebrae N. Intericosto Brachialis Smooth Muller’s Orbital Muscle 24 Thoraco Dorsal N.

10 Lower Trunk

7

Mi

k un Tr

6 Up per Cord

The Brachial Plexus Root Trunk Cord and Terminal Innervation

xi

ry

N.

Large Sensory Pathway

Small Sensory Pathway

Brachio Cutaneous N.

20 Ulnar N . Antibrachio Cutaneous N.

18 Median N.

s N. taneou

81


ll a

d

d

u culoc 16 Mus


Fig. 4-8 ■ The Stevens diagram of the brachial plexus (Modified from Stevens JH with assistance from Kerr AT: Brachial plexus paralysis. In Codman EA, ed: The shoulder, Malabar, FL, 1934, Robert E. Krieger. Used with permission.)

11

. e rv

Ro

9 C

V II

e 5 C

D

N.

or

e rM

i al

al

A

or s

d Ra

T h or ac ic

I

a

nn e

He

1s t Ro ot

n di a Me r te

di a n He a

Phrenic N. IV branch when 1 Dorsalis Scapulae N. present. The 4c branch which Henle’s loop we found so often represented here present in the schematically, vertebral canal with but really lower 2 Subclavian N. the artery which 3 Subscapular N. down. comes from 4c and 4 C erv. V R oot 3c also sometimes

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82


C. 6 months D. 12 months E. One cannot know unless the hand surgeon performs diagnostic testing.

Supraclavicular n. (C3, C4) Axillary n. (C5, C6) Superior Lateral Brachial Cutaneous

Radial n. (C5-C8) Inferior Lateral Brachial Cutaneous

Superficial br.

Median n. (C6-C8,T1) Palmar cutaneous

Palmar digitalis

Intercosto brachial n. (T1, T2) and medial brachial cutaneous n. (T1) Medial antebrachial cutaneous. (C8, T1) Musculocutaneous n. (C5, C7) Lateral Antebrachial Cutaneous Ulnar n. (C8, T1) Dorsal Palmar cutaneous cutaneous Dorsal Palmar digitalis digitalis Palmar digitalis

Radial n. (C5-C8) Posterior Brachial Cutaneous Inferior Lateral Brachial Cutaneous Posterior Antebrachial Cutaneous

Superficial br. and dorsal digitalis

Median n. (C6-C8,T1) Palmar digitals

Fig. 4-9 ■ Adapted with permission from Netter FH: The atlas of human anatomy, ed 2, Summit, NJ, 1997, CIBA-GEIGY Corp.

The rate of nerve regeneration is inversely proportional to the distance from the cell body. A Tinel’s sign is one way to measure a regenerating axon. When Wallerian degeneration occurs, rates of regeneration vary according to body part (e.g., in the upper arm, regeneration occurs at 8.5 mm/day, whereas 1 to 1.5 mm/day [1 inch/month] has been reported and accepted in the forearm and hand). In this case study, your patient injured herself roughly 6 inches from her fingertip. Nerve regeneration would be expected in approximately 6 months because the distance to the fingertip is roughly 6 inches. Interestingly, the traditional concept that regenerating axons take 3 weeks to cross the suture line and another 3 weeks to establish function once the distal end of the axon reaches its target end organ is now viewed as incorrect by some authors.

Hunter, p. 618 Dellon, pp. 38-43

43. The controversy over how hard to press the prongs when doing two-point discrimination testing has been resolved by an instrument that records the pressure at which the patient can distinguish one from two points. What is the instrument? A. B. C. D.

WEST device Current perception threshold device (neurometer) EAST device PSSD

Answer: E Malick, Kasch, pp. 19, 26

42. Your patient injured her hand on the volar aspect of the palm at the metacarpal head on the radial side of the index finger, 6 inches from her fingertip. She is experiencing sensory loss. How long would you anticipate the nerve to take for her feeling to return after digital nerve repair? A. 3 weeks B. 3 months

The WEST device is a form of the nylon monofilaments and cannot measure two-point discrimination. There is no EAST device. The neurometer introduces electrical wave forms as a stimulus and cannot measure pressure thresholds. The unique property of the PSSD is that it measures the pressure required to distinguish one from two points pressing against the skin. These points can be moving or static.

changes, hair growth, and rate of healing) functions. After nerve injury, early sympathetic changes include rosy, warm, and dry skin without gooseflesh. Trophic changes include soft, smooth skin texture with hair falling out or becoming longer and finer. Late changes after sympathetic nerve injury include mottling or cyanosis and cool skin with no pilomotor function. The skin is nonelastic; the patient develops curved (talon-like) nails; and hair continues to fall out and become longer and finer. To treat sympathetic dysfunction, the therapist must return moisture to the skin with daily soaking and oil massage, inspect the patient daily for pressure areas, and use tools or splints that assist in injury prevention.

Answer: C

Answer: D Dellon, 1997, Ch. 7


A. Stroke an eraser end across the targeted area. B. Have your patient identify a variety of objects placed in a bag. C. Occlude your patient’s vision and have him identify various coins. D. All of the above are excellent tools for early sensory reeducation.

Early sensory reeducation may begin when 30 Hertz and moving touch are perceived. Your goal in early reeducation is to correct false localization and have the patient learn to distinguish constant from moving touch. Early reeducation can be accomplished by stroking or pressing an object (e.g., an eraser end of a pencil or a cotton-ball) to the targeted area. This is completed first with the patient’s eyes opened, thus allowing the patient to observe the process. Next, the patient’s eyes are closed, and the patient is told to concentrate on the stimulus. Afterward, the patient should open his eyes to observe the stimulus. Having the patient verbalize the location of perceived movement or pressure when his eyes are opened and closed is helpful. A patient will perceive stroking first, followed by constant touch and pressure. Dellon invented the terms early and late sensory reeducation in 1970. Answers B and C are performed in latephase reeducation, which is reeducation of object identification. Attempting object recognition before all sensory submodalities have regenerated to the fingertip is pointless. Keep in mind that some authors divide sensory reeducation into protective and discriminative rather than early and late phases. Answer: A Skirven, Callahan in Mackin, Callahan, Skirven, et al, p. 615 Fess in Mackin, Callahan, Skirven, et al, pp. 635-639 Dellon, 1997, pp. 20, 246-295

A. B. C. D.

About About About About

2 mg worse 2 mg worse 2 mg/mm2 worse 100 times worse

The numerical marking on the nylon monofilament introduced by Sidney Weinstein and Josephine Semmes is the logarithm to the base 10 of the force in tenths of milligrams. Thus the difference between markings of 3 and of 5 is one hundred fold—or ten to the second power.

44. A 52-year-old man is referred to you for sensory reeducation. Your examination reveals that he cannot perceive 256 Hertz (Hz), but is able to perceive 30 Hz. He exhibits difficulty with localization and touch recognition. Which treatment modality would help with early sensory reeducation?

45. A patient who is being followed in therapy for recovery after a nerve injury has a change in his or her cutaneous pressure threshold with the Semmes-Weinstein nylon monfilaments that goes from a 3.17 to a 5.07. This change demonstrates that the patient has become which of the following?

Answer: D Dellon, Mackinnon, Brandt, pp. 756-757

46. A patient has neurosensory testing that stages his degree of cubital tunnel syndrome as mild. The therapist begins nonoperative treatment with splinting and activity of daily living (ADL) modifications. The patient is followed for 3 months. What percentage chance does the patient have for improving? A. B. C. D.

80% 50% 25% 10%

It has been demonstrated that 80% of patients who change their ADLs for 3 months can resolve their cubital tunnel syndrome complaints without surgical decompression. The success of nonoperative treatment decreases with increasing degrees of nerve compression.

CLINICAL GEM: The PSSD became available in 1989. It detects a different sequence of sensory loss in chronic nerve compression. It is an instrument designed to measure touch threshold (one-point static, one-point moving, two-point static, and twopoint moving).

83

Answer: A Dellon, Hament, Gittelsohn, pp. 1673-1677

47. If the posterior cord of the brachial plexus were injured, paralysis would be expected in which of the following muscles? A. Latissimus dorsi B. Deltoid


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The posterior cord receives contribution from all three trunks in the brachial plexus. The posterior cord gives rise to the following five nerves: 1) the upper subscapular nerve, which supplies the subscapular muscle; 2) the lower subscapular nerve, which supplies the teres major and a branch of the subscapularis; 3) the thoracodorsal nerve, which supplies the latissimus dorsi; 4) the axillary nerve, which supplies the deltoid muscle and teres minor; and 5) the radial nerve, which supplies the extensors of the elbow, wrist, and digits. The coracobrachialis muscle is innervated by the musculocutaneous nerve, which is part of the lateral cord (see Fig. 4-8). Answer: F Malick, Kasch, pp. 6-9 Hunter, Mackin, Callahan, pp. 888-891, 1875

48. A 32-year-old man sustained a brachial plexus injury. He cannot control shoulder abduction or forward elevation. He can extend his elbow but cannot actively flex his elbow. He is experiencing sensory loss in the thumb and index fingers. The middle finger sensation is intact. Which nerve roots are damaged? A. B. C. D.

C5 and C6 C5, C6, and C7 C6, C7, and C8 C7 and C8

The brachial plexus anatomy is formed by the anterior primary rami of C5, C6, C7, C8, and T1 and their terminal outflow of the peripheral nerves. Injury to the brachial plexus involves commonly observed patterns. In this case study, the lesion involves the C5 and C6 roots. The paralysis of the deltoid and lateral rotators of the humerus and elbow flexors indicates this particular level of injury. In addition, the sensory loss of the thumb and index fingers is the result of C5 and C6 root damage; the middle finger (C7) is spared (see Fig. 4-8). Answer: A Hunter, Mackin, Callahan, p. 636 Whitenack, Hunter, Read in Mackin, Callahan, Skirven, et al, pp. 703-719 Hunter, Whitenack in Mackin, Callahan, Skirven, et al, pp. 733-734

49. After carpal tunnel decompression using an open technique, the patient complains of pain sensation in the scar near the wrist. The pain does not radiate to any of the fingers and finger sensibility is normal. No significant improvement has occurred after 6 months of desensitization techniques, including massage, steroid iontophoresis, and fluidotherapy. What would be the appropriate treatment at this point? A. B. C. D.

Neurolysis of median nerve Nerve graft of median nerve Further therapy Resection of the palmar cutaneous branch of the median nerve

If there is normal sensibility in the thumb and index finger, no treatment is required for the median nerve. In this case the symptoms are from a neuroma of the palmar cutaneous branch of the median nerve. This nerve must be resected and the proximal end placed in a quiet location away from the skin and wrist joint movements.

C. Extensor carpi radialis longus/extensor carpi radialis brevis D. Coracobrachialis E. A and D F. A, B, and C

Answer: D Evans, Dellon, pp. 203-206

50. After a nerve repair at the wrist, when can “final” evaluation of nerve recovery be assessed? A. B. C. D.

6 months 2 years 4 to 5 years The nerve is in perpetual recovery.

After a nerve suture or nerve graft at the wrist, nerve regeneration to the fingertips occurs by 1 year. After another year of sensory reeducation, final assessment can be performed at 2 years after surgical nerve repair.

84

Answer: B Dellon, pp. 38-43

51. After resection of the radial sensory and lateral antebrachial cutaneous nerves and implantation of these nerves into the brachioradialis muscle, a patient complains of paresthesia in the dorsoradial aspect of the wrist. What is the best explanation for a patient’s complaints? A. B. C. D.

Recurrent neuroma pain Regeneration of the resected nerves Collateral sprouting from adjacent normal nerves Reflex sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS)


25 45 60 90

degrees degrees degrees degrees

In brachial plexus injuries, the therapist should be careful not to increase tension on the brachial plexus roots. Coronal abduction—especially coronal abduction combined with lateral rotation—may cause tension on the brachial plexus roots if the arm is abducted above 90 degrees. Because the rotator cuff often is paralyzed, which may result in humeral subluxation and abduction, shoulder motion beyond 90 degrees puts additional stress on the capsule and should be avoided. Answer: D Hunter, Mackin, Callahan, p. 648 Walsh in Mackin, Callahan, Skirven, et al, pp. 742-750

53. The goals of therapy during treatment of a patient experiencing brachial plexus injuries include which of the following? A. B. C. D. E.

Answer: E Hunter, Mackin, Callahan, pp. 647-655 Walsh in Mackin, Callahan, Skirven, et al, pp. 742-760

Answer: C Dellon, Aszmann, Muse, pp. 520-525

52. When one is evaluating the upper limb in a patient with a brachial plexus injury, care should be taken during examination of the shoulder joint. To prevent stress on the roots of the brachial plexus, which maximal shoulder abduction should be allowed? A. B. C. D.

loss, depression, or difficulty dealing with the loss. In addition, the goals of therapy are to protect the limb from additional trauma, prevent contractures, and monitor sensory and motor recovery.

Protecting the limb from additional trauma Preventing contractures Monitoring sensory recovery Addressing psychological issues All of the above

A brachial plexus injury is a devastating, complex event that requires a team approach to treatment. Both psychological distress and physical involvement affect the functional outcome. The healthcare team should help with psychological issues related to functional

54. The term Klumpke palsy refers to which brachial plexus level of injury? A. B. C. D.

(C5), C6, C7 C6, C7 C7, C8 (C7), C8, T1

Klumpke palsy is an uncommon lesion in the adult population. It involves the (C7), C8, and T1 nerveroots. The shoulder, elbow, and wrist extension are intact. Loss of finger flexion, extension, and intrinsic function of the hand is observed. The sensory loss may be severe and usually involves the little finger, ring finger, and medial aspect of the forearm (see Fig. 4-8).

The nerve growth factor released from the distal portion of the resected nerve can stimulate neural regeneration into this region from uninjured adjacent nerves. This is termed collateral sprouting. It is a shortlived protective mechanism that will benefit from further desensitization and sensory reeducation. Therefore, collateral sprouting is the best answer.

85

Answer: D Kozin, Ciocca, Speakman in Mackin, Callahan, Skirven, et al, p. 836

55. You are treating a patient 4 weeks after distal fingertip amputation. Primary healing has occurred. He describes extreme hypersensitivity and also reports that the fingertip feels as if it is going to burst. Which contact particle or texture would be best for this patient during initial treatment? A. B. C. D.

Velcro hook Burlap texture Cotton balls High-cycle continuous vibration

Desensitization programs should be initiated at the level of vibration texture and contact medium that the patient can tolerate. A patient with extreme hypersensitivity, as described in this situation, would not be able to tolerate Velcro hook, burlap texture, or high-cycle continuous vibration. Initiating treatment with moleskin texture, felt, or cotton would be more appropriate for this patient. This patient probably would benefit from retrograde massage during the early stage of hypersensitivity. The patient also should work on a home


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program that uses contact particles and dowel textures to assist with desensitization. Vibration often is more uncomfortable initially, but according to Janet WaylettRendall, vibration eventually is preferred over any other desensitization media. Hand-held, battery-operated vibrators can be issued for home use. Answer: C Hunter, Mackin, Callahan, pp. 698-699 Mackin, Callahan, Skirven, et al

Refer to Fig. 4-10

pression syndromes rather than complete loss (see Fig. 4-9).

86

Answer: A Tubiana, Thomine, Mackin, p. 318 Kandel, Schwartz, p. 304

57. Winging of the scapula can result from injury to several different shoulder girdle muscles but is classically attributed to which of the following muscle/nerve combinations? A. B. C. D.

Serratus anterior/suprascapular nerve Serratus anterior/axillary nerve Supraspinatus/long thoracic nerve Serratus anterior/long thoracic nerve

Fig. 4-10

56. A patient who complains of complete loss of sensation in the ring and little finger and along the medial forearm has loss of sensation caused by: A. B. C. D.

C8 nerve-root damage Cubital tunnel compression Guyon canal compression C7 nerve-root damage

Each dorsal root innervates a particular area of skin called a dermatome. This patient has loss of sensation from C8 dorsal nerve-root damage. The dermatome for C8 is the ring finger, little finger, and the medial forearm. A relationship exists between dermatomes and areas innervated by peripheral nerves. The ulnar nerve and the antebrachial cutaneous nerve are the peripheral nerves that correspond to the C8 dermatome. Sensory changes associated with cubital tunnel compression usually are confined to the ulnar aspect of the hand and the ulnar one and a half digits. In nerve compression syndromes, patients rarely have a complete loss of sensation. Alterations of sensitivity result in nerve com-

The serratus muscle is innervated by the long thoracic nerve and is the classical cause of winging of the scapula. The suprascapular nerve innervates the supraspinatus muscle which does influence shoulder function. The axillary nerve innervates the deltoid, which also influences shoulder function (see Fig. 10-3). Answer: D Disa, Wang, Dellon, pp. 79-84

58. True or False: Neural gliding to the affected arm is an appropriate treatment for a patient in the irritable phase of thoracic outlet syndrome.

When a patient is in an irritable state (constant pain that is easily provoked and may take a long time to settle), treatment should revolve around rest, with activities limited to those functions that produce minimal or no discomfort. Between rest periods, the patient must avoid activities and postures that strain or aggravate the tissue. Patients initially may need the support of a sling, pillow, or abduction wedge for the shoulder to reduce pain. When irritability is reduced to a moderate or minimal level, neural gliding exercises may be initiated to the unaffected extremity; examples would include neural gliding on the uninvolved arm or a straight leg raise. Nonirritable neural restrictions can be treated with nerve gliding techniques. The upper limb tensioning techniques, as proposed by Butler, restore neural motion in patients who are in a nonirritable state. Nerve gliding must begin without development of tension in the involved extremity, especially in patients who previously


were highly irritable. Patients can be progressed to increased neural tension and postural ergonomic instructions in preparation to return to activities. Next, strengthening conditioning should ensue for return to full activity.

87

Lateral intermuscular septum

Extensor compartment

Medial intermuscular septum

Answer: False Neurovascular bundle

Whitenack, Hunter, Read in Mackin, Callahan, Skirven, et al, pp. 723-724 Butler, pp. 104-105

59. When a patient is evaluated for complaints of numbness in the thumb and index finger after a carpal tunnel decompression, it is important to consider a more proximal site of compression for the median nerve, instead of recurrent carpal tunnel syndrome. What proximal compression site would you suspect?

Flexor compartment

Lacertus fibrosus


A. Deep head of the pronator teres or the lacertus fibrosis B. The arcade of Froshe C. The medial head of the triceps D. Fascia between the brachioradialis and extensor carpi radialis longus

Fig. 4-12

The Arcade of Froshe is a fascial covering of the supinator muscle that compresses the posterior interosseous nerve. The medial head of the triceps can compress the ulnar nerve proximal to the elbow. The radial sensory nerve can be compressed as it exits fascia adjacent to the brachioradialis tendon. The median nerve can be compressed in the forearm beneath the deep head of the pronator teres, the lacertus fibrosis, or the ligament of Struthers (not “arcade”).

Malick, Kasch, p. 19

Answer: A Rosenberg, Conolley, Dellon, pp. 258-265

CLINICAL GEM: Absence of the “gooseflesh” response occurs when there is complete interruption of sympathetic supply to an area (Mackin, Callahan, Skirven et al, p. 226).

Refer to Fig. 4-11

60. Which sympathetic function is called gooseflesh (Fig. 4-12)? A. B. C. D.

Answer: B

Vasomotor Pilomotor Sudomotor Trophic

Pilomotor function or the “gooseflesh” response is of the skin in the upper extremity. Fig. 4-12 depicts an exaggerated response of one’s hair “standing on end.”

61. Which obstetric palsy most often affects the C5 and C6 nerve roots? A. B. C. D.

Erb’s palsy Duval’s palsy Seddon’s palsy Klumpke’s palsy


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88


Obstetric palsy traction injuries are caused by fetal malposition, cephalopelvic disproportion, or the use of forceps. Erb’s palsy is an upper brachial plexus palsy that most often affects the C5 and C6 nerve roots. It includes paralysis of the supraspinatus, infraspinatus, deltoid, biceps, brachialis, and brachioradialis muscles. Lower brachial plexus injury, known as Klumpke’s or Dejerine Klumpke type, involves the C8 and T1 nerve roots. This injury results in paralysis of the flexors and extensors of the forearm, with sparing of the brachioradialis, supinator, pronator teres, extensor carpi radialis longus, and extensor carpi radialis brevis muscles. The hand intrinsic muscles and part of the triceps are paralyzed. Sensory loss with this injury is severe.

CLINICAL GEM: The following are nerve injury correlations between Seddon’s classification (as described in question 62) and Sunderland’s classification (a frequently referenced peripheral nerve injury classification):

Answer: A

Recovery potential

I

Neuropraxia

Axon maintained; stimulation can occur distal to lesion; possible segmental demyelinization

Full

II

Axonotmesis

Loss of axonal integrity with distal axonal degeneration (Wallerian degeneration); endoneurial tube intact

Full

III

Axonotmesis

Endoneurial tube torn; perineurium intact

Slow; incomplete

IV

Axonotmesis

Only epineurium intact

Neuroma-incontinuity is common

V

Neurotmesis

Complete transection of the nerve

None

Green, p. 1510 Kozin, Ciocca, Speakman in Mackin, Callahan, Skirven, et al, p. 836

62. True or False: In 1943, Seddon introduced a three-part classification of the injured peripheral nerve. The mildest form of nerve injury in Seddon’s categorization is referred to as a neurotmesis.

Answer: False Skirven, Callahan in Mackin, Callahan, Skirven, et al, p. 602 Butler, p. 176

63. True or False: Scar tissue may be the culprit in neuroma development.

A neuroma results from a blocked regenerating nerve. This block may have various causes, one of which may be scar tissue. The block causes the regenerating sprouts to become trapped and surrounded by connective tissue. By definition, a neuroma is not painful. When a neuroma is in a vulnerable environment related to tendon or joint movement, the entrapped ends of the failed regenerating axons send painful messages when stimulation occurs from the motion of surrounding tissues. The diagnosis of a neuroma is easy to make because direct tapping over the nerve elicits a painful paresthesia. Conservative treatment consists of iontophoresis, desensitization, protective splinting, ultrasound, transcutaneous electrical nerve stimulation, or steroid injection.

The first part of Seddon’s three-part classification is the neuropraxic injury, which is the mildest form of nerve injury. The neuropraxic injury is a local conduction block; with this injury the prognosis is excellent because the axonal continuity and nerve conduction is preserved proximal and distal to the injury. The second part, which is called axonotmesis, is more severe because axonal disruption leads to Wallerian degeneration of the distal axon. Wallerian degeneration is a degeneration of the distal axon; it takes place over a period of 1 to 2 months. Recovery time varies with axonotmesis and prognosis is good. The most severe type of injury is the third part, called neurotmesis, which involves complete transsection of the entire nerve trunk. Prognosis is poor unless surgical repair is performed.

Sunderland’s Seddon’s Injury classification classification

Answer: True Dellon, pp. 44, 45 Herndon in Green, Hotchkiss, Pederson, pp. 1469-1479


89

Descriptions CLINICAL GEM: The term neuroma-in-continuity refers to a neuroma in a nerve that has not been completely severed.

A. Clawing of the ring and little finger B. Hyperextension of the metacarpophalangeal joint of

the thumb in pinch grip C. Pronounced flexion of the thumb interphalangeal

Signs 1. 2. 3. 4. 5. 6. 7.

Froment Jeanne Wartenberg Duchenne Egawa Andre-Thomas Masse

F. G.

64. Match the following signs with their corresponding descriptions. Note that all relate to ulnar nerve paralysis.

D. E.

joint during adduction toward the index finger (key pinch) Flattening of the metacarpal arch Wrist falls into volar flexion during action of the extensors to the middle finger Inability to adduct the extended little finger to the extended ring finger Inability of the flexed middle finger to abduct radially and ulnarly and to rotate at the metacarpophalangeal joint

Answers: 1, C; 2, B; 3, F; 4, A; 5, G; 6, E; 7,

D Tubiana, Thomine, Mackin, p. 280


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Chapter 5

Modalities

1. 2. 3. 4.

Paraffin Hot pack in hydrocollator Fluidotherapy Whirlpool

Temperature Application (F) A. B. C. D.

102° to 118° 113° to 129° 158° to 167° 96° to 104°

The temperature of the material that provides the heat is not necessarily the crucial factor in the amount of heat transmitted to the body and the resultant safety of the modality. An increase of 1° or 2° F has dramatic, localized physiologic effects. An increase in temperature of more than 5° F usually results in a burn. The superficial heating modalities are essentially equivalent in their ability to deliver heat to the body. Water with the greatest specific heat (the amount of heat energy stored at a particular temperature) is delivered at the coolest temperature. Paraffin has a lower specific heat than water and is delivered at a higher temperature, and so on with fluidotherapy. Moist heat packs are separated from the patient by several layers of toweling because they are kept at the highest temperature in the hydrocollator. Answers: 1, B; 2, C; 3, A; 4, D Michlovitz, pp. 117, 119, 123, 160

A. B. C. D.

Accelerate healing of soft tissue Decrease muscle tone Decrease calcium deposits in bursae Decrease spasticity

US has been shown to accelerate the healing of soft tissues. Answers B, C, and D are all based on anecdotal evidence only. Answer: A Prentice, pp. 293-294

3. Uncomfortable, achy sensations associated with US may be avoided in which of the following ways? A. B. C. D.

Increasing frequency Decreasing intensity Increasing the size of the treatment area All of the above

All of the above can assist with decreasing uncomfortable, achy sensations associated with US. Achy sensations emanate from overheating of the periosteum. Increasing the frequency of US decreases the depth of penetration. Decreasing the intensity decreases the amount of heat generated by US. Increasing the size of the treatment area lowers the spatial averaged intensity of the US and limits the amount of energy received by any given area of underlying periosteum. 91

5 MODALITIES

Modality

2. Ultrasound (US) has been shown to do which of the following?

1. Match each of the following modalities to the correct temperature application.

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CHAPTER 5 ■ Modalities

Answer: D Prentice, pp. 279-282

92

4. Which of the following benefits occurs when applying US with the soundhead while the patient’s hand is immersed in water, versus direct placement of the body part with the use of gel?

A. Voltages that never exceed 120 volts B. Frequencies (pulses per second) of at least 50 C. Frequencies, voltages, and intensities sufficient to elicit action potentials in motor nerves D. Intensities of at least 50 milliamps

Electric stimulation to elicit muscle contractions could be performed with a virtually infinite number of combinations of frequency, voltage, and intensity. The crucial feature of any given set of parameters is its ability to generate an action potential in a motor nerve, characterized by “strength-duration” curves. Strengthduration curves illustrate the minimal combinations of voltage, intensity, and duration required to generate action potentials, and detailed information on these may be found in any introductory textbook on electrical stimulation.

A. B. C. D.

Acoustical streaming Minimal impedance Microvibration of pores Hyperfractionation of medication

Acoustical streaming is the term for the overall movement of molecules away from the source of sound; medications placed on the skin are literally pushed into deeper structures, although research has failed to provide strong evidence for this application.

5. The parameters for electrical currents applied to elicit muscle contractions include which of the following?

6. US can facilitate the movement of medications through the skin because of which of the following?

Answer: A Belanger, p. 240

7. Intermittent compression pumping should do which of the following? A. Be set no higher than 50 mm Hg for the upper extremity B. Have a ratio of 3 : 1 of inflation to deflation C. Not exceed the patient’s diastolic blood pressure D. All of the above

Adhering to all of the above guidelines is important when using the intermittent compression pump.

Answer: A Prentice, pp. 289-293

Baker, Wederich, McNeal, p. 11

CLINICAL GEM: Terminology Clarification: Neuromuscular electrical stimulation (NMES) is a general term that describes a group of stimulators that use pulsating current to stimulate innervated musculature. This type of stimulation is used for maintaining or gaining range of motion, facilitating a muscle contraction, and substituting for orthoses. The application of electrical stimulation for orthotic substitution is also termed functional electrical stimulation (FES).

A. Prevention of damage to the soundhead because of poor contact with gel and/or body surfaces B. Less nonuniformity of intensity to the treatment area C. Improved transmission of US to deeper tissues D. More even dosage of US intensity throughout the treatment area E. Increased nonthermal effects of the US treatment

Prevention of damage to the soundhead caused by poor contact with gel and/or body surfaces can be avoided by performing US in water. The soundhead may be damaged if it is not in contact with transmission gel and the underlying body part. US cannot be transmitted through solids or gases and may reverberate within the soundhead. Water and gel are both excellent transmission media for US, and the physical and physiologic effects of both treatment techniques are virtually equal.

Answer: C

Answer: D Hayes, p. 71

Refer to Fig. 5-1

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93

Cold packs to manage posttraumatic edema should be applied for 20 minutes on and 20 minutes off during the first 24 hours after trauma, if possible. Treatment time should not exceed 20-minute intervals. Answer: D Prentice, pp. 211-213

10. True or False: Fluidotherapy is safer than other superficial heating modalities because it can be applied at a much higher temperature.

8. Which of the following is false about cold therapy?

Answer: False Prentice, pp. 233-234

Refer to Fig. 5-2

A. It is the thermal agent of choice for the first 24 to 48 hours after injury. B. It decreases inflammation. C. It decreases pain. D. All of the above are true.

All of the above are considered accurate. There is controversy in the literature regarding the effects of cold therapy; therefore further research is warranted. Answer: D Michlovitz, pp. 84-86

9. At the end of superficial cold applications, the skin is often red. This is evidence of reactive hyperemia, the body’s attempt to restore blood flow to an area recently deprived of blood and the oxygen it carries. Therefore when cold is applied to minimize posttraumatic edema, what is the maximum treatment time? A. B. C. D.

5 minutes 10 minutes 15 minutes 20 minutes

Fig. 5-2

11. Increased tissue temperature is a thermal effect of US. How does this increased temperature affect the blood flow to the treated area? A. B. C. D.

The tissue has a decrease in blood flow. The tissue has an increase in blood flow. The tissue has no change in blood flow. The tissue initially has a decrease in blood flow, followed by an increase in blood flow.

5 MODALITIES

CLINICAL GEM: Not all schools of thought use intermittent pumps to treat lymphedema. However, if utilized, sequential pumps with gradient pressure are much more effective for treating lymphedema than are one-chamber intermittent pumps.

Fluidotherapy uses particles of cellulose (e.g., sawdust) that are suspended in air as the conductive medium. The specific heat of this combination is very low; in other words, the amount of heat energy it contains at any given temperature is much less than that of water and it can therefore be much hotter. So, fluidotherapy is neither safer nor more dangerous than any other type of superficial heating modality. It simply can be hotter because of its low specific heat capacity.

Fig. 5-1

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The principal reason for using US for thermal effects is elevated tissue temperature. With increased tissue temperature, a normal response is an increase in blood flow. Answer: B Michlovitz, pp. 177-179

12. US should be avoided with which of the following types of patient? A. B. C. D.

Under 16 Over 55 Has a history of hypertension Has a history of cancer in an unrelated location

14. When treating supraspinatus tendonitis with US, which shoulder position is most beneficial? A. B. C. D.

Arm abducted and internally rotated Arm externally rotated and abducted Position of comfort Position that most aggravates pain

When one is using US as a treatment modality for supraspinatus tendonitis, the position of choice is with the arm abducted and internally rotated to expose the supraspinatus tendon from under the acromion process.

94

Answer: A Michlovitz, p. 203

Refer to Fig. 5-3

US has been shown to disrupt epiphyseal plates (growth plates) in long bones; therefore it should be avoided in those who are still growing. There is a potential for US to facilitate metastasis of cancerous lesions, but it is not carcinogenic and may be used on patients with a history of cancer. Answer: A Michlovitz, pp. 177-179

13. True or False: It is important to heat US gel for patient comfort and to increase transmission.

Heating US gel is inadvisable because it makes the gel runny and decreases viscosity, which leads to runoff. Gel is an excellent coupling agent for transmission. Using gel helps to decrease air bubbles and friction. Heating increases the oxygen in gel, thus decreasing the coupling medium’s effectiveness. Water is an adequate coupling medium; however, increased air bubbles in water reduce transmission. Answer: False Michlovitz, p. 199

CLINICAL GEM: A quick reference to gel temperature follows: Less than 66° F = 90% effective Greater than 66° F = 73% effective

Fig. 5-3

15. You are treating a stiff digit with abundant scar tissue. Which US frequency would be best for elongating the scar? A. B. C. D.

1 MHz 3 MHz 1.5 w/cm2 1.0 w/cm2

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Hunter, Mackin, Callahan, p. 23 Michlovitz in Mackin, Callahan, Skirven, et al, pp. 1746-1748

16. Intermittent compression pumps may be used with all but which of the following? A. B. C. D. E.

Postmastectomy lymphedema Venous insufficiency Arterial insufficiency Amputations Traumatic edema

Patients with arterial insufficiency have increased peripheral resistance and compression worsens this condition. Other contraindications include infections, thromboses, cardiac dysfunction, kidney dysfunction, obstructed lymphatic channels, and cancer (see Fig. 5-1).

Answer: B Hecox, Mehreteab, Weisberg, pp. 424, 427

18. Which of the following explains the usefulness of “spray and stretch” techniques? A. Spray and stretch is useful because rapid, brief cooling of the skin over a muscle reduces muscle tone. B. Spray and stretch is useful for facilitating relaxation of muscles in spasm secondary to trauma. C. Spray and stretch is only useful if performed with proper technique, which includes spraying parallel to muscle fibers, proximal to distal, at a speed of about 10 cm/second. D. All of the above

D is correct. Spray and stretch, developed by Travell in the 1960s, is a variation of cryotherapy (cold therapy) and has been reported to be useful when specific indications and techniques are employed. Answer: D Travell, Simons, pp. 65-74, 503-504 Prentice, pp. 219-220

Refer to Fig. 5-4

Answer: C Hayes, p. 71

17. An 80-year-old woman slipped and fell on wet pavement. She landed on an outstretched arm, which resulted in a Colles’ fracture of her right wrist. After 6 weeks in a cast, the patient continues to suffer from severe, chronic edema of the wrist and hand. Her treatment included intermittent pneumatic compression (IPC). Necessary chart information for determining progress when treating this condition with IPC would include which of the following? A. Right wrist muscle strength B. Pretreatment and posttreatment measurements of girth of the right forearm and wrist C. Grip strength D. Active range of motion of right wrist flexion and extension E. Right forearm and wrist sensation Fig. 5-4

5 MODALITIES

Answer: B

The comparison of girth measurements before and after treatment and from treatment to treatment is an important clinical indication of the effectiveness of IPC.

When a depth of penetration of up to 2 cm is desired, the therapist should use 3-MHz US, which is ideal for treating hand and wrist pathologies. US has been shown by some authors to be helpful in elongating scar tissue. A 1-MHz US treatment is best used to treat deeper tissue when desired penetration is up to 5 cm in depth. 1 MHz is ideal for treating the back and lower extremities. Answers C and D are incorrect because they relate to intensity.

95

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19. The use of the Jobst compression pump is not contraindicated in the presence of which of the following? A. B. C. D. E.

Infection Vascular damage Pain Fractures It is contraindicated for all of the above.

Compression units should not be used when a patient has an active infection, vascular damage, and/or unhealed fractures. If using a compression pump increases the patient’s pain level, it should be modified or discontinued; however, pretreatment pain is not a contraindication to the use of a compression unit. Answer: C Malick, Kasch, p. 98

20. True or False: Melzack and Wall theorized that small-diameter fibers of light touch and proprioception can close the gate to pain fibers.

According to the theory of Melzack and Wall, the “gate” opens to stimuli that approach the central nervous system (CNS) with high speed. Therefore sensations that travel along large-diameter nerve fibers (non-nociceptive) inhibit pain or tend to “close the gate” to pain, especially the throbbing, dull pain typically reported by patients suffering from musculoskeletal trauma. Small-diameter (nociceptive) fibers elicit pain or “open the gate.” Thermal sensations and sensation of electrical stimulation are carried by large-diameter fibers and are the most commonly used physical agents to close the gate in clinical practice. Answer: False Hunter, Mackin, Callahan, p. 1536 Fedorczyk, Barbe in Mackin, Callahan, Skirven, et al, pp. 1729-1730 Mense, Simons, p. 348

21. True or False: You have a patient with hypergranulation tissue on his hand wound. You choose to treat this patient with a lukewarm whirlpool for 15 minutes. This is the best method of treatment.

Hypergranulation tissue, also called proud flesh, occurs when granulation tissue continues to form over the original wound. The proper way to treat such a wound is with the application of silver nitrate or corticosteroid cream. A therapist should cease using whirlpool and consider using semipermeable dressings on the wound and decrease the frequency of wound cleansing and dressing changes.

CLINICAL GEM: Ethyl chloride and fluorimethane are common sprays; however, ethyl chloride is not recommended. Fluorimethane is safer to use but can freeze the skin when a stream is directed on one area for 6 seconds or longer; therefore fluorimethane should be used with caution.

Answer: False McCulloch, Kloth, Feedar, p. 143

22. The use of whirlpool treatments has decreased in past years. This is most likely the result of which of the following? A. Advances in wound care, including occlusive and semipermeable dressings B. Increased consciousness of the dangers of transmitting infection from patient to patient C. Efficacy of medications to enhance peripheral circulation D. All of the above

The popularity of whirlpool treatments began in an era when they represented the state of the art in cleaning wounds, facilitating healing, and improving peripheral circulation. However, the use of whirlpools has declined for all of the above stated reasons. Refer to Chapter 6, Wounds/Infection, for additional information concerning moist wound healing.

96

Answer: D Belanger, pp. 347-350

23. Which of the following patients might benefit from contrast baths as a treatment modality? A. A patient with small-vessel disease secondary to diabetes B. A patient with arthrosclerotic endarteritis C. A patient with Buerger’s disease D. A patient who has arthritis of the peripheral joints E. All of the above patients are poor candidates for contrast baths.

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97


Hunter, Mackin, Callahan, p. 1371 Michlovitz in Mackin, Callahan, Skirven, et al, p. 1748 Michlovitz, pp. 161-162

CLINICAL GEM: For severe edema, some authors advocate ending contrast bath treatment in cold water for 1 minute.

24. True or False: Continuous passive motion (CPM) enhances the healing and regeneration of musculoskeletal tissues.

CPM enhances the healing and regeneration of musculoskeletal tissues, including articular cartilage, synovial membranes, joint capsules, ligaments, and tendons. CPM also is used to overcome joint stiffness and pain, and it minimizes the effects associated with immobilization. Answer: True Hunter, Mackin, Callahan, p. 1545 LaStayo, Cass in Mackin, Callahan, Skirven, et al, p. 1764

Refer to Fig. 5-5

CPM is probably effective in preventing or overcoming joint stiffness because of the machine’s ability to provide low-load prolonged stress (LLPS) to tissues. The phenomenon of LLPS is best explained by Atkinson and others, who state that “the fibroblasts of the fibrous connective tissue matrix apparently respond to physical forces by a homeostatic biofeedback loop to maintain the proper balance of tissue constituents.” LLPS addresses structural changes in the tissues after trauma and stiffness after immobilization. Understanding of the mechanics of LLPS and its effects on connective tissue is still somewhat speculative. Answer: True Hunter, Mackin, Callahan, p. 1546 LaStayo, Cass in Mackin, Callahan, Skirven, et al, pp. 1766-1767

26. For which of contraindicated? A. B. C. D.

the

following

is

CPM

Burn patients Capsulotomies Fractures with open reduction internal fixation Unstable fractures

CPM is indicated for fractures that are stable after open reduction internal fixation. CPM is not indicated for an unstable fracture. It is, however, indicated in surgical release of joints, capsules, tendons, and extraarticular scar adhesions. CPM has indications for use with surgical repair of tendons or repair of ligaments. Other indications include overcoming joint stiffness, inflammatory conditions, pain, burns, and total joint replacements. Answer: D Hunter, Mackin, Callahan, pp. 1548-1551 LaStayo, Cass in Mackin, Callahan, Skirven, et al, p. 1768

27. For lateral epicondylitis, the best form of cold therapy for local anesthesia to facilitate the performance of active and/or passive range of motion (ROM) treatment is which of the following? A. B. C. D.

Cold pack Ice massage Cold bath Controlled cold-compression units

5 MODALITIES

Answer: D

25. True or False: CPM can provide low-load prolonged stress.

A patient with flexible implant arthroplasties of the metacarpophalangeal joints might benefit from the use of contrast baths. All of the answers except D describe patients who cannot use contrast baths as a treatment modality. Caution also should be exercised when using contrast baths for a patient with peripheral vascular disease if the water temperature is set higher than 40° C (104° F). Contrast baths are used for patients with arthritis of the peripheral joints, joint sprains, and muscle strains and to toughen amputation stumps. Unfortunately, no well-controlled study of the efficacy of contrast baths is available. If a contrast bath is used, the temperature should be between 38° C (104° F) and 44° C (111.2° F) in one basin and 10° C (50° F) to 18° C (64° F) in the other basin. The extremity to be treated should be placed in the warm basin for 10 minutes, then immersed in the cold basin for 1 minute, and then returned to the warm basin for 4 minutes. This cycle should be continued for 30 minutes, with the last immersion being in the warm basin.

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98


A

B

C

Fig. 5-5

■ Examples of CPM devices used in treating the upper extremity patient. A, JACE S600 shoulder chair-mount CPM; B, JACE H440 hand rehabilitation system; C, JACE W550 portable wrist CPM. (Courtesy JACE Systems, Cherry Hill, NJ.)

An ice massage is the best technique for treating a small area such as in lateral epicondylitis. Ice massage also is helpful when treating a muscle belly, bursa, or trigger point. An area 10 ¥ 15 cm can be covered in 5 to 10 minutes. When ice massage is performed, it is not uncommon for a patient to experience cold followed by burning, then aching, and finally numbness or analgesia. Answer: B Michlovitz, pp. 99-100

Refer to Fig. 5-6

CLINICAL GEM: A quick way to remember the order of physiological events during ice massage is to think of CBAN: Cold; Burning, Aching; Numbness.

28. Match each electrical stimulation parameter to the corresponding word(s): Parameter 1. Amplitude 2. Pulse duration

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99

Increasing the pulse rate from 20 to 80 yields a slight increase in strength but also induces more rapid onset of fatigue. Rates higher than 80 produce no known benefit. The duty cycle—or on/off time adjustment—has profound effects on fatigue. Duty cycles of 10 seconds on to 10 off (a 1:1 ratio) tend to fatigue muscles within several minutes. In contrast, duty cycles that use a 1:5 ratio (e.g., 15 seconds on and 75 seconds off) allow the muscles to be active for 30 minutes longer. The rise time, or surge time, is the length of time from the onset of the current until its highest intensity. A gradual rise in intensity (long rise time) yields a gradual increase in muscle strength.

3. Frequency 4. Rise time 5. On time/off time

Baker, Wederich, McNeal, pp. 91-105

30. Match each wave form to the corresponding current: Wave Form 1.

Word(s) A. B. C. D. E.

+1

Rate, pulse/second, Hz Width Duty cycle Intensity Ramp/surge

0 –1

2.

Answers: 1, D; 2, B; 3, A; 4, E; 5, C Hunter, Mackin, Callahan, p. 1512 Michlovitz in Mackin, Callahan, Skirven, et al, p. 1753

3.

29. During use of electric stimulation to elicit muscle contractions, increasing the _________ will increase the strength of the contraction. A. B. C. D.

Intensity (amperage) Pulse rate Rise, or surge, time Duty cycle

4.

Current Many parameters relate to electrical stimulation for muscle contraction. Although nonlinear, they may be summarized as follows: with all other factors held equal, increasing the intensity of current results in increased strength of contraction. Increasing the pulse rate above 20 pulses per second results in a smoother contraction.

A. B. C. D.

Biphasic short duration current Direct current Polyphasic sinusoidal alternating current Monophasic short duration current

5 MODALITIES

Fig. 5-6

Answer: A

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Answers: 1, B; 2, D; 3, A; 4, C Hunter, Mackin, Callahan, p. 1511 Michlovitz in Mackin, Callahan, Skirven, et al, pp. 1752-1753

31. True or False: You are treating a patient after flexor tendon repair with electrical stimulation to increase the pull-through of his flexor digitorum profundus (FDP) to the middle finger. You notice with your current electrode placement that you are only getting the flexor digitorum superficialis to fire. One option would be to move the electrodes further apart to result in deeper penetration of current.

Rheobase is the minimum intensity required to elicit a minimally visible contraction when the duration is infinite and the chronaxie is twice the rheobase. Although it is excitable tissue, denervated muscle requires a stimulus of higher amplitude and longer duration than does a normally innervated muscle. Sensory nerve tissue responds more quickly than a motor (muscle) nerve and requires a lower intensity and shorter duration than muscle tissue.

100

Answers: A, True; B, True; C, False;

D, False Hecox, Mehreteab, Weisberg, pp. 277-278 Meyer, pp. 124, 225

Refer to Fig. 5-7

150

Nerve fiber

Muscle fiber

120 Strength (volts)

Although correct in theory, an increase in the distance between electrodes in practice often does little to increase depth of penetration. A more effective strategy for eliciting contractions of deeper muscles is the placement of one electrode over a superficial aspect of a motor nerve, and the other electrode over the muscle belly. In this example, an electrode placed in the cubital fossa will elicit contractions of the portion of the FDP that activate the second and third digits, and an electrode placed over the ulnar nerve will elicit contractions of the portion of the FDP that activate the fourth and fifth digits.

90

Chronaxie Rheobase

Chronaxie

60

Rheobase 30

0.01 0.03 0.1 0.3

1

3

10

30 100 300

Answer: True Baker, Wederich, McNeal, pp. 144-146

32. Strength-duration tests help determine the excitability of nerve and muscle tissues. Test results are plotted on log paper with the stimulus intensity on the Y axis and duration on the X axis. The relative position of the curve and the rheobase and chronaxie are identified on the graph. Answer true or false to the following statements: A. Rheobase is the minimum intensity required to elicit a minimally visible contraction when the duration is infinite. B. Chronaxie is the duration required for a stimulus with twice the rheobase intensity to elicit a visible contraction. C. The strength-duration curve of a denervated muscle requires a lower intensity for a given duration than does an innervated muscle. D. Sensory nerve tissue has a higher threshold than muscle tissue.

Fig. 5-7

■ Strength duration curve of nerve and muscle fiber. (From Hunter JM, Mackin EJ, Callahan AD: Rehabilitation of the hand: surgery and therapy, ed 4, St Louis, 1995, Mosby.)

33. True or False: Most commercially available muscle stimulators require that the cathode (negative pole) be placed on the motor point, and the anode (positive pole) be placed distally.

Most commercially available stimulators are biphasic, or alternating, current stimulators. This means that each electrode alternates between positive and negative polarity throughout the treatment.

Duration (msec)

Answer: False Belanger, Wederich, McNeal, pp. 347-350

CLINICAL GEM: One way to remember polarity is to recall that A+ (anode+) is a better grade than C(cathode-).

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Long-pulse durations are required to overcome the capacitance of muscle fibers—that is, their ability to resist depolarization by artificial means. Electrical stimulation (ES) to elicit muscle contractions actually works by depolarizing motor nerve fibers. In the 1950s, longduration currents were only available in combination with direct currents; therefore many therapists relying on textbooks of that era assume that A is the correct answer. Unfortunately, long-pulse durations evoke significantly more skin impedance than short ones, thus heating of the skin. Increases in skin temperature easily lead to burns if the skin is denervated, which often accompanies denervation of muscles. Because of the high risk of burns, very few manufacturers produce ES devices with durations long enough to elicit contractions of denervated muscle.

Answer: D Hecox, Mehreteab, Weisberg, p. 297 Hunter, Mackin, Callahan, p. 1517 Michlovitz in Mackin, Callahan, Skirven, et al, pp.1755-1758

36. Iontophoresis is chosen to treat edema and pain on the dorsum of a wrist. Which of the following is incorrect with regard to setting up iontophoresis treatment? A. Clean skin and perform a sensation assessment. B. Use an interrupted direct current generator. C. Use an active electrode with the opposite polarity of the ion to be delivered. D. Place a second, larger dispersive electrode on a distant area. E. Electrodes should be buffered by the manufacturer.

An active electrode with the same polarity as the ion to be delivered is necessary. The ions are delivered to the tissues while they are repelled by an electrode with the same polarity. All of the other answers are correct statements regarding iontophoresis. Answer: C Hecox, Mehreteab, Weisberg, pp. 296-297 Michlovitz in Mackin, Callahan, Skirven, et al, pp. 1757-1758

Refer to Fig. 5-8

Answer: B Baker, Wederich, McNeal, pp. 85-86

35. A 33-year-old active tennis player developed a gradual onset of extensor tendonitis in the right forearm and is unable to play tennis secondary to severe, sharp pain at the common extensor tendon origin when extending his wrist. Iontophoresis has been indicated as a treatment option. Which solution is the most appropriate choice for this diagnosis? A. B. C. D.

Copper sulfate Saline Lidocaine Dexamethasone

This patient has developed lateral epicondylitis. Dexamethasone is the most appropriate solution to use with iontophoresis. Dexamethasone is an antiinflammatory and is effective for treating arthritis, bursitis, and tendonitis with iontophoresis.

101

Fig. 5-8

5 MODALITIES

A. Direct current B. Any current with a long-pulse duration (>1000 microseconds) C. Alternating current D. All of the above

34. Which type of current should be used with denervated muscle tissue (pick the best answer)?


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CLINICAL GEM: Medications used for iontophoresis Drug

Preparation strengths

Polarity

Dexamethasone

4 mg/ml

Negative

Lidocaine Salicylate

4%-5% solution 10% trolamine salicylate ointment or 2%-3% sodium salicylate solution

Positive Negative

Clinical identification Inflammatory conditions (tendonitis, bursitis, arthritis) Analgesia Arthritis

Adapted from Ciccone CD: Pharmacology in rehabilitation, ed 2, Philadelphia, 1996, FA Davis. In Mackin EJ, Callahan AD, Skirven TM, et al: Rehabilitation of the hand and upper extremity, ed 5, St Louis, 2002, Mosby.

A. B. C. D.

Conventional Low-rate Brief, intense All of the above

The brief intense technique involves a brief and intense high-rate (above 100 pulses/second) and high-width (above 200 microseconds) current at an intensity as high as the patient can tolerate. Brief intense transcutaneous electrical nerve stimulation produces a tetanic contraction and results in surface analgesia for 10 to 15 minutes. This is a noxious stimulus and is best used with and before painful procedures such as burn debridement, passive stretching, or minor surgery.

102

Answer: C Hecox, Mehreteab, Weisberg, p. 302

Refer to Fig. 5-9

37. A 25-year-old man presents with pain of the left wrist 2 days after playing in a racquetball contest. Which of the following treatment parameters is most appropriate for decreasing pain during treatment that uses ES? A. Continuous, high voltage at 50 to 120 Hz for 10 to 30 minutes B. Surged, Russian stimulation at 2500 Hz for 30 to 60 minutes C. Interrupted, low voltage at 5 Hz for 20 minutes D. None of the above is appropriate.

To help reduce acute pain, high-voltage ES is often used, with a rate of 50 to 120 Hz for 10 to 30 minutes. A continuous mode is most effective because the patient can comfortably tolerate an ongoing, unmodified series of pulses. This mode allows muscle relaxation and a reduction in pain. Answer: A Meyer, p. 215 Hecox, Mehreteab, Weisberg, pp. 266-267

38. Which of the following transcutaneous electrical nerve stimulation modes is appropriate when painful procedures (e.g., debridement) are performed on a patient?

Fig. 5-9

39. Which of the following is true about using ES for the acceleration of wound healing? A. It is still considered experimental. B. It is no longer considered useful. C. It is considered an adjunctive therapy by the Centers for Medicare and Medicaid Services (CMS). D. It is useful only if the patient has poor sensation.

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autogenic inhibition secondary to pain, or to teach patients how to keep their activation consistent to minimize tremor.

Prentice, p. 151

Answer: C Medicare coverage issues manual, Transmittal 166

CLINICAL GEM: Terms to remember EMG stands for electromyography. Electro- means electrical activity. Myo- means muscle. -Graphy means graphical representation.

40. The ideal parameters for treating wounds with ES include which of the following?

All of the above are correct. Although there is much room for variation depending on available technology and/or patient comfort, these guidelines are based on large-scale, multicenter studies of the past decade. Answer: E Kloth, McCulloch, p. 305

41. Electromyographic (EMG) biofeedback is most useful for which of the following? A. Training patients to better control the neural activation of skeletal muscle B. Strength-training C. Desensitizing patients who have extreme fear of moving after painful injury D. Increasing the speed of reinnervation after traumatic injury to motor nerves

EMG biofeedback is a technique to collect and display the neural signals that activate skeletal muscle. Although teaching patients to increase the level of activation may result in strength gains, the primary usefulness is to teach control of neural activation of skeletal muscle. Hence EMG biofeedback might be useful after cerebrovascular accident and in cases of

42. Mr. X has carpal tunnel syndrome and is referred for “cold” laser treatment. What is your therapeutic intervention? A. B. C. D.

US with cold pack ES with ice pack Low-level laser therapy (LLLT) All of the above

LLLT has been successfully used around the world for more than 25 years. The Food and Drug Administration (FDA) recently cleared LLLT for carpal tunnel syndrome. LLLT reduces inflammation, stimulates nerve function, develops collagen and muscle tissue, helps generate new and healthy cells and tissues, increases blood supply, and reduces acute and chronic pain. LLLT is a painless, sterile, noninvasive, drug-free treatment that is used to treat a variety of pain syndromes, neurologic conditions, and pathologies.

A. Direct currents of 75 to 100 volts B. Pulse rate of ~100 C. Positive electrode over the wound to stimulate epithelialization D. Negative electrode over the wound to stimulate formation of granulation tissue E. All of the above

Answer: A

Answer: C Batter, et al, pp. 171-178

CLINICAL GEM: The Microlight 830 is a state-of-the-art LLLT device that was designed by a team of doctors and leading medial engineers to harness the therapeutic application of advanced low energy laser technology. Visit www.laserhealthproducts.com for more information.

5 MODALITIES

According to the CMS, very good evidence suggests that ES can accelerate the healing of most types of wounds, although the use of ES—or lack thereof—is far from the most crucial factor in wound healing. It is far less important than the presence or absence of infection, intact circulation, and good overall nutritional status.

103

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Chapter 6

Wounds/Infection

1. 2. 3. 4.

Autolytic Debridement Denuded Eschar

Definition

A. B. C. D.

Leathery thick necrotic tissue, often dry and black Loss of epidermis Removal of necrotic tissue Disintegration or liquefaction of tissue or cells by the body’s own mechanisms

Answer: 1, D; 2, C; 3, B; 4, A Topical wound care algorithms, glossary Hess, pp. 21-36 Evans, McAuliffe in Mackin, Callahan, Skirven, et al, pp. 322-324

2. All but which of the following are terms used for the inflammatory stage of wound healing? A. B. C. D.

Exudative Proliferative Lag Substrate

Answer: B

6 WOUNDS/INFECTION

Term

Exudative, lag, substrate, and inflammatory are all terms for the first stage of wound healing; proliferative, fibroblastic, and reparative are all names for the second stage of wound healing. The first stage of wound healing is a complex arena of cellular activity; this stage begins with injury and usually lasts 3 to 5 days. Stage two lasts until day 21 and is termed proliferative with respect to collagen deposition and connective tissue. An infected wound cannot progress to stage two of wound healing. Stage three (the remodeling stage) generally begins around day 21 and may last for 24 months. This stage focuses on contraction and collagen degradation. It is important to understand that the three stages of wound healing overlap and are influenced by many variables. These variables include—but are not limited to—diet, age, infection, and other medical conditions. All of these factors can alter wound-healing time frames.

1. Match the following term with the appropriate definition.

Hunter, Mackin, Callahan, p. 228 Evans, McAuliffe in Mackin, Callahan, Skirven, et al, p. 323 Smith, Price in Mackin, Callahan, Skirven, et al, p. 331 McCulloch, Kloth, Feedar, p. 3

Refer to Fig. 6-1

3. Autolysis is the method of debridement that occurs naturally and can be facilitated by moist wound dressings. Which of the following wounds would be suitable for this method of debridement?

105

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106

CHAPTER 6 ■ Wounds/Infection

Stage II Proliferative Phase

2 years

Repair

0 End Stage I Injury

Fig. 6-1

4 days

End Stage II 21 days

11 months

End Stage III 2 years

■ Time frame of wound healing stages.

A dry eschar-covered wound A patient who cannot tolerate surgical debridement A patient who has a coagulation disorder All the above

All of the above are appropriate candidates for autolytic debridement. Autolytic debridement allows the body to break down necrotic tissue by using the body’s enzymes and defense mechanisms. Autolytic debridement is accomplished by using a variety of moist wound healing dressings, which can help maintain a moist wound environment and thereby promote reepithelialization. They also have been shown to reduce pain and provide a barrier to infection. Many moist wound-healing dressings that will promote autolysis are available.

Bryant, Rolstad, p. 4 Hess, pp. 22, 68

4. The inflammatory stage in an untidy wound is completed in how many days? 2 days 5 days 10 days The length of this stage is indefinite.

Answer: D Hunter, Mackin, Callahan, pp. 237-238 Smith, Price in Mackin, Callahan, Skirven, et al, pp. 331-332

5. Match each of the following terms with the correct definition. Term 1. 2. 3. 4. 5.

Collagen Chemotaxis Dehiscence Exudate Ground substance

Definition A. Accumulation of a fluid in a cavity, matter that pen-

B.

C. D.

Answer: D

CLINICAL GEM: Hydrocolloid, alginate, or hydrogel dressings can be used to achieve natural autolytic cleansing.

A. B. C. D.

In a clean (tidy) wound, the inflammatory stage often lasts 5 days. In an untidy wound, the inflammatory stage lasts indefinitely until debris is cleaned from the wound. Severe trauma to the tissues, infection, excessive manipulation of the tissue in surgery, aggressive therapy, and inappropriate wound management are among the causes of a prolonged inflammatory stage.

E.

A. B. C. D.

Stage III Remodeling Phase

Stage I Inflammatory Phase

etrates through vessel walls into adjoining tissue, or the production of pus or serum A fibrous, insoluble protein found in connective tissues that represents about 30% of total body protein The bursting open of a wound The fluid, semifluid, or solid material that occupies the intercellular space in fibrous connective tissue, cartilage, or bone The movement of additional white blood cells to an area of inflammation in response to the release of chemical mediators by neutrophils, monocytes, and injured tissue

Answers: 1, B; 2, E; 3, C; 4, A; 5, D Taber’s cyclopedic medical dictionary Evans, McAuliffe in Mackin, Callahan, Skirven, et al, pp. 311-328

6. A diagnosis of malnutrition can be made if which of the following is true? A. B. C. D.

Patient receives tube feedings Serum albumin levels are below 3.5 mg/dl Total lymphocyte count is above 1800 mm3 Weight is appropriate for patient’s height

Ch06.qxd 7/28/04 6:37 PM Page 107

CHAPTER 6 ■ Wounds/Infection

107

Table 6-1

Markers of Malnutrition Marker Percent of usual body weight Albumin, g/dl Prealbumin, mg/dl Transferrin, mg/dl Total lymphocyte count, mm3

Normal value 100%

Mild depletion 85% to 95%

Moderate depletion 75% to 84%

Severe depletion 200 2500

2.8 to 3.4 10 to 15 150 to 200

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